Hospital and Clinic Invoice Template

Free invoice templates for hospitals and clinics built for physician fees, facility fees, and lab tests. Download and edit in PDF, Word, Excel, Google Docs, or Google Sheets.

Also called: hospital and clinic invoice, hospital and clinic bill, or clinic visit invoice.

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Download Free Hospital and Clinic Invoice Templates

Download a template, then edit in PDF, Word, Excel, Google Docs or Google Sheets. Print or email when ready.

Sheets, Excel, Word and Doc Templates Coming November 21, 2025.

Custom Hospital and Clinic Invoice Template

Best for:

Logo, NPI, payer fields, payment plan.

Editable Hospital and Clinic Invoice Template

Best for:

Edit codes, modifiers, auth, notes, add labs.

Printable Hospital and Clinic Invoice Template

Best for:

Copay, insurance, claim ref, signatures.

Free Hospital and Clinic Invoice Template

Best for:

CPT, ICD-10, units, diagnosis, balance.

How to Invoice as a Hospital or Clinic

Collect clean info, submit the claim fast, then invoice the patient with clear terms.

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In 5 Steps:

Verify eligibility, benefits, and any preauthorization, and capture patient demographics before the visit.
Estimate charges, explain costs, and collect the copay or required deposit for elective care.
Deliver care and document services with CPT/HCPCS codes, diagnoses, and supply quantities.
Submit the claim to insurance, post EOB adjustments and payments, and resolve any denials.
Issue the patient invoice showing remaining responsibility, apply any deposit, and set payment terms.

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What to Include in a Hospital or Clinic Invoice

These are the must-have fields for clear, compliant invoices.

Invoice number and issue date
Facility or clinic name, address, phone, and email
Patient full name and date of birth
Patient ID or MRN and account number
Insurance plan name and member ID
Attending or ordering provider name and NPI
Billing NPI and Tax ID
Authorization or referral number (if required)
Date(s) of service and place of service
Mandatory patient notices (balance billing/surprise billing rights; check local rules)

Billing Scenarios for Hospitals and Clinics

How to label charges so every invoice makes sense the moment your clients see it.

Emergency visit; Imaging/lab tests

Emergency department visit with imaging and labs

The base visit is separate from diagnostic testing performed during the visit.

Office visit; Procedure fee

Office visit with in-room procedure

Evaluation time and minor procedures are billed separately.

Telehealth visit; Technology fee

Telehealth video consultation

Remote care may include a small platform or facility charge.

Diagnostic imaging; Contrast material

Outpatient imaging with contrast material

Use separate lines for services and supplies with quantities and unit prices to keep costs transparent.

Pre-surgery deposit; Applied to final bill

Elective surgery scheduling deposit

The deposit secures resources and is credited to the final balance.

Cancellation fee; Short-notice window

The fee covers lost appointment time that could not be rebooked.

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Patient charges and facility fees for hospitals and clinics

Itemize physician fees, facility fees, lab tests, procedures, copays, and deductibles with professional invoice line items.

Charge or Service

Unit

Taxable

When to use

How to show it

Initial Consultation/Exam

Time

New patient or first visit

Time × hourly rate. Document chief complaint and findings to justify medical necessity.

Facility/Room Fee

Item

Use of procedure or recovery room

Qty × rate. Tie to encounter ID and chart notes for audit trail.

Surgical Procedure Charge

Item

Physician-led procedure completed

Qty × rate. Reference CPT/description and attach consent for clear billing.

Anesthesia Time

Time

Anesthesiologist or CRNA time

Time × hourly rate. Record start/stop times and ASA status for accuracy.

Imaging Study (MRI/CT/X-ray)

Item

Diagnostic imaging performed

Qty × rate. Include modality, body part, and radiology report number.

Laboratory Panel

Item

Bloodwork or panel ordered

Qty × rate. Link to order, collection time, and results release for compliance.

Specimen Collection & Handling

Item

Venipuncture or sample collection

Qty × rate. Note specimen type and chain-of-custody to support test billing.

Telehealth Visit

Time

Video or phone encounter

Time × hourly rate. Capture platform used and patient consent in notes.

DME Brace/Boot Dispensed

Item

Taxable

Patient takes home orthopedic device

Cost × (1 + markup%). Record size, brand, and serial/lot if applicable.

After-Hours Urgent Visit Surcharge

Item

Visit outside standard hours

Qty × rate. Use only when policy defines after-hours; note timestamp.

Save and reuse your hospital and clinic fees

Create a free account and save physician fees, facility charges, labs, and copays once, so nothing gets retyped.

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Common Hospital and Clinic Invoicing Mistakes

Healthcare billing is messy, but small fixes keep patients calm and payments on track. Use these to prevent disputes.

Mistake

How to fix it

Using only codes without plain-language descriptions confuses patients and slows payment.

Pair each code with a short, plain description and unit count so people can match the service to the bill.

Leaving out compliance identifiers like billing NPI or tax ID triggers insurer or HSA rejections.

Put identifiers in the header and double-check them against your practice system; check local rules.

List the service date and, when relevant, start and stop times for timed services.

Use separate lines for services and supplies with quantities and unit prices to keep costs transparent.

Requesting payment before showing insurer payments, adjustments, and write-offs causes overpayment and refunds.

Present the EOB math in order: allowed amount, insurer payment, adjustments, then patient responsibility.

Omitting payment terms, late fees, refunds, or payment plan options results in missed or delayed payments.

State the due date, accepted methods, late fee policy, refund rules, and how to set up a payment plan.

Hospitals & Clinics Invoice FAQs

Line-item help for medical centers: CPT/HCPCS, implants, facility and professional splits, telehealth, self-pay terms, and the Hospitals & Clinics Invoice Template. Clear answers.

Can we split facility and professional charges on one bill?

Yes. Show the hospital’s facility fee and the physician group’s professional fee as separate lines. Example: “99233 Professional E/M: $210” and “Facility Fee G0463: $185.”

What coding details should appear to avoid payer denials?

List CPT/HCPCS codes, units, modifiers, and the primary ICD-10 diagnosis. Example: “93000 ECG x1, Dx: I10, Modifier 26: $45.”

Can a clinic charge a no-show or late cancel fee?

Yes, with posted policy and patient consent. Rules vary—check local rules. Example: “No-Show Fee, 24-hour notice required: $40.”

How do we bill implants and high-cost drugs so they aren’t bundled?

Use revenue code and HCPCS with units and invoice cost, plus markup if allowed by contract. Example: “C1776 Cardiac Stent x1: $2,300 cost, 10% markup.”

What needs to be listed for telehealth visits to pay correctly?

Add place of service, telehealth modifier, and provider NPI. Example: “99213-95 Telehealth, POS 11, Provider NPI #######: $110.”

When can we add an after-hours or urgent care surcharge?

When payer contracts or policies allow it and signage notifies patients. Rules vary—check local rules. Example: “After-Hours Surcharge S9088: $45.”

What documentation must accompany a workers’ comp claim?

Include employer name, claim number, date of injury, and adjuster details. Example: “Workers’ Comp Claim #WC123456, DOI 04/02/2025: Visit 99214: $165.”

How should we price self-pay visits under the No Surprises Act?

Give a Good Faith Estimate up front and reflect any prompt-pay discount on the bill. Rules vary—check local rules. Example: “Self-Pay GFE 99203: $140, Prompt-Pay Discount 20%: −$28.”