Printable Medical Insurance Form Invoice

The medical insurance form invoice template is a readymade format that is used by insurance companies for preparing the billing requirements of their client. Such a template can be used by both private and government insurance agencies according to the need that is why it must contain general lineation. This invoice usually covers the medical policy and the basic medical insurance options opted by the customer and the charges accordingly. The medical insurance form invoice template is an important document as it acts as a record for future references for both parties. It is important to fill in all the details carefully in order to avoid any miscommunication. However, this document can also be customized depending on the varied needs of either party.

You can Download the Free Medical Insurance Form Invoice Template form, customize it according to your needs and Print. Medical Insurance Form Invoice Template is either in MS Word, Excel or in PDF.

Sample Medical Insurance Form Invoice Template

Medical Insurance Form Invoice Template

Download Medical Insurance Form Invoice Template

Medical Insurance Form Invoice

Insurance Company Name: _____________ [State the official name of the insurance company]Address:_______________________
____________________________________Phone no.:_____________

 

Website:_____________________ [if any]

 

Invoice no.__________

 

Date of Invoice:___________ [dd/mm/yy]

 

Customer Information: [Provide the necessary contact information and insurance policy details opted by the customer]Name:Address:

 

Medical Insurance Policy No.:

 

Name of Medical Insurance Policy:

 

Date of Application:_______ [dd/mm/yy]

Medical Insurance Form Details:

[State the essential details of the medical insurance policy]

Coverage Date Medicaid Id no. Premium Insured Employee   Premium Insured Amount Reimbursed

Billing Information:

Amount payable:Insurance Agent Fee:Service Tax:

 

Grand Amount:

 

To be paid within:________ to __________ [State the period within which all payments must be cleared by the customer]

Preferred Payment Options:Bank Account No.____________Bank Name:________________

 

Mode of Payment:_____________

 

 

 

Signature of Customer:___________________Signature of Insurance Agent:_______________

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