Your Clinic Name
Patient
Patient Full Name
456 Patient Street
City, State 00000
patient@email.com
DOB: Jan 1, 1985
City, State 00000
patient@email.com
DOB: Jan 1, 1985
Provider
Dr. Your Name, MD
123 Medical Plaza, Suite 100
City, State 00000
clinic@youremail.com
License #: MED-000000
NPI: 0000000000
City, State 00000
clinic@youremail.com
License #: MED-000000
NPI: 0000000000
| Description | Qty | Rate | Amount |
|---|---|---|---|
|
Office Visit — Established Patient CPT: 99213 — Level 3 Evaluation |
1 | $185.00 | $185.00 |
|
Blood Panel — Comprehensive CPT: 80053 — Lab Work |
1 | $95.00 | $95.00 |
|
Flu Vaccination CPT: 90686 — Immunization |
1 | $45.00 | $45.00 |
|
Copay Adjustment Insurance applied |
1 | -$75.00 | -$75.00 |
Subtotal
$250.00
Tax (0%)
$0.00
Total Paid
$250.00
Payment Received
Payment received in full on March 5, 2026.
Method: Credit Card
Auth Code: 000000
Thank you for choosing our practice.
Method: Credit Card
Auth Code: 000000
Thank you for choosing our practice.
Notes
This receipt may be used for insurance or FSA/HSA reimbursement.
Please retain for your records.
Questions? Contact us at clinic@youremail.com
Please retain for your records.
Questions? Contact us at clinic@youremail.com
Thank you for trusting us with your care. We look forward to seeing you at your next visit.
Medical Receipt FAQ
What should a medical receipt include?
A medical receipt should include the provider's name, license or NPI number, and contact information; the patient's name; a unique receipt number; the date of service; an itemized list of procedures and fees; total amount paid; payment method; and any insurance adjustments applied.
Can patients use a medical receipt for insurance or FSA/HSA reimbursement?
Yes. A detailed medical receipt is typically required for insurance claims and FSA/HSA reimbursement. Include the provider's NPI or license number, CPT procedure codes if applicable, and the date of service. Check with your insurer or plan administrator for specific requirements.
Is this medical receipt template free?
Yes, completely free — no account, no watermark, no time limit. Create and download as many medical receipts as you need for your clinic or practice.
Should I include tax on a medical receipt?
Most medical and healthcare services are tax-exempt in the United States. Leave the tax rate at 0%. If you sell taxable retail items (supplements, medical devices), set the appropriate tax rate in the Tax field.
Will my patient data be saved if I close the browser?
Your edits are saved in your browser's local storage only — nothing is sent to any server. If you close the tab and return, your data will still be there. Always download a PDF copy for your records.