Invoice Physiotherapist in Belgium Brussels –Free Word Template Download with AI
Dr. Jean-Pierre Dubois, Licensed Physiotherapist
Avenue Louise 250, Box 4
1050 Brussels, Belgium
Phone: +32 2 555 0199
Email: [email protected]
Enterprise Number (KBO/BCE): BE 0891.234.567
VAT Number: BE 0891.234.567
Invoice Number: INV-2023-10-045
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Payment Reference: REF-BRU-99281
Bill To (Patient)
Mr. Thomas Anderson
Rue de la Loi 155
1040 Brussels, Belgium
National Register Number (RNI): 910415 123 45 67
Insurance / Payer
Mutualité Libre Chrétienne (MLC)
Attention: Reimbursement Department
Policy Number: MLC-99887766
Reference: Medical Certificate #MED-2023-88
| # | Description of Physiotherapy Services | Code (Nomenclature) | Qty | Unit Price (EUR) | Total (EUR) |
|---|---|---|---|---|---|
| 1 |
Manual Therapy Session Assessment and manual mobilization of the cervical spine and shoulder girdle. Treatment of myofascial pain syndrome in the upper trapezius. Performed in accordance with the Belgian nomenclature for physiotherapists. |
701.01 | 1 | 35.00 | 35.00 |
| 2 |
Electrotherapy / TENS Application of Transcutaneous Electrical Nerve Stimulation for pain management and muscle relaxation. Session duration: 20 minutes. |
701.02 | 1 | 15.00 | 15.00 |
| 3 |
Therapeutic Exercise Program Guided rehabilitation exercises focusing on core stability and lumbar spine strengthening. Instruction on ergonomic posture for office work in Brussels. |
701.03 | 1 | 35.00 | 35.00 |
| 4 |
Consultation and Assessment Initial comprehensive evaluation of musculoskeletal condition. Review of medical history and imaging results (MRI). Formulation of treatment plan. |
701.00 | 1 | 45.00 | 45.00 |
| 5 |
Home Exercise Plan Documentation Preparation of a detailed written and visual guide for daily exercises to be performed at home. Includes safety instructions. |
701.05 | 1 | 20.00 | 20.00 |
Payment Instructions & Important Information
Bank Transfer (Preferred):
Bank: KBC Bank Brussels
IBAN: BE68 5390 0754 7032
BIC: KREDBEBB
Please use the Payment Reference indicated above.
Insurance Reimbursement:
This invoice is compliant with the regulations of the Belgian National Institute for Health and Disability Insurance (RIZIV/INAMI). Please submit this document to your mutual insurance fund (Mutualité) for reimbursement. Note that the "Insurance Contribution" listed is an estimate based on standard reimbursement rates for Brussels residents; actual amounts may vary depending on your specific policy.
Late Payment:
In accordance with Belgian law regarding late payment of commercial debts, interest may be charged on overdue amounts after the due date.
Legal Disclaimer and Professional Standards:
This invoice represents services rendered by a licensed Physiotherapist registered with the Brussels Capital Region Health and Social Services Commission (CSS/OCMW). All treatments described herein were performed in strict adherence to the ethical code and professional standards established for physiotherapy practice in Belgium. The codes referenced correspond to the official Belgian nomenclature for medical and paramedical acts. This document serves as a legal record of the transaction between the provider and the patient. By accepting these services, the patient acknowledges that physiotherapy is a medical intervention and that results may vary based on individual health conditions. This invoice is valid for tax purposes in Belgium and the European Union. For any disputes regarding this invoice, the competent court is the Court of First Instance of Brussels.
Data Privacy:
Your personal data is processed in accordance with the General Data Protection Regulation (GDPR) and Belgian privacy laws. Your information is kept confidential and is used solely for billing, medical record-keeping, and insurance processing purposes.
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