Medical Records Invoice Template is to bill a patient or another office for the transfer of a patient’s medical and health care history. In accordance with the HIPAA laws (45 § 164.524(c)(4)), a medical office or covered entity that is transferring records on behalf of another party may only charge fees that are “reasonable and cost-based” in relation with the following:
Generally, the fee should not be more than $20 to $50 unless a special request, such as expedited delivery, is made.
1 – Secure A Copy Of The Medical Records Invoice
The “PDF” or “Word” button included on this page near the image will each grant access to the medical records invoice displayed in the image. Similarly, the text links above will connect you to the same file so that you can download it to your machine (for future use).
2 – Identify the Medical records Company
Substitute the words “Company Name” at the top of this page with the Medical Records Company’s legal name. 
The “Name” of an individual who can represent the Medical Records Company in this matter should be recorded on the first labeled blank line in this header area. 
The address the Medical Records Company uses to receive business mail needs to be documented. The building number and street name of this address is requested on the “Street Address” line. Bear in mind that if the mailing address includes a suite number or a PO Box, this should be recorded on this line.
The two lines that follow in this area will need the “City, State, Country” of the Medical Records Company address and the last item, the “Zip Code,” will be needed on the next available space. 
The final labeled spaces require the concerned Sender’s current “Phone” and “E-Mail” details supplied to their contents.
3 – Present Preliminary Information
The Medical Records Company issuing this paperwork will likely have assigned a filing number that is unique in its system. This number must be reported on the “Invoice #” line. 
This paperwork must make an effort to clearly identify all the parties that are directly involved with it. In this case, you will be required to submit the information that names the concerned “Patient” and directly addresses the Medical Records Company Client. Let us begin this process by inputting some basic “Patient Information.” Turn your attention to the column on the left then record the legal “Name,” current “Age,” and the “Gender” of the Patient involved. 
The second column, under “Bill To,” contains several labeled areas. Make a submission of the Medical Records Company Client’s “Name” and the mailing address where this paperwork is being sent. 
4 – Summarize The Medical Record Services Being Billed
A table has been produced to the center of this page. This table will intend to define what recordkeeping services are being billed and how much they are being billed for. It will also summarize what must be paid in full to satisfy this document. The “Description” column will accept a clear report on the record-keeping services provided. If this information is not available by lot or by contract, you can satisfy this area with the date range where payment is requested. 
The “Amount” box in this table requests the price of the services you have defined. Record the “Amount” of money being charged. 
Add all the amounts that must be paid to one “Subtotal” and enter this number in the second box down this column. 
The third box down this column calls for the “Tax” that the Medical Records Company must add to its charges. 
Finally, the “Total” box needs the sum of the “Subtotal” being charged and the “Tax” being charged. Make certain this calculation is accurate then input it to the box labeled “Total.” 
The sentence that starts with the words “Payment Is…” will need some input from you to be complete. The number of “Days” the Medical Records Company allows to elapse before considering a payment late must be produced on the blank space in this sentence.
1 – Access The Medical Records Invoice In A Spreadsheet Format
The invoice displayed on this page with the “PDF” and “Word” can be used by a Medical Records Company to bill its Clients.
2 – Present The Medical Record Company As The Sender
Introduce the Medical Records Company as the Sender by uploading and placing its logo in cell A1 and its entire legal name in cell A2. There will also be an area where the “Name” of the person responsible for this paperwork in cell A3. Produce this “Name” then proceed to fill out cells A4, A5, and A6 with the “Street Address,” the “City, State, Country,” and the “ZIP Code” of the Medical Records Company mailing address.
The “E-Mail” and telephone number of the Medical Records Company must be produced to fields making up A7 and A8 (as requested). 
3 – Set Some Details To The Contents Of This Spreadsheet
We will need to attend to several parts of this spreadsheet. Begin with the table occupying the top of columns F and H. Locate cell F4 and substitute the text it displays with the invoice number the Medical Records Company will use to track the status of this invoice. Cell H4 is set with the current calendar day as the invoice “Date” but can be edited if desired. 
Two sections below this will expect material identifying the Medical Records Patient and Client. First, attend to the “Patient Information” section in column A. Use cells A11 through A13 to present the Patient’s “Name,” his or her “Age,” then his or her “Gender” by replacing these text labels in these cells with the Patient’s details. 
Column E has reserved cells E11, E12, and E13 for the Medical Record Client’s “Name,” “Street Address,” and “City, State, Country.” The “Zip Code” for the address being recorded should be presented in the next field down this column where it is requested separately. 
4 – Invoice The Medical Record Service Requiring Payment
Use cell A18 as the staging area for the medical record production or maintenance work that was done for the Client. The information you record here must be readily understood by the Client so make certain to be as specific or general as required. 
Cell H18, to the right of this “Description,” also needs attention. Specifically, record the price of the medical record services being billed. 
The “Subtotal” cell (H19) is the sum of all the medical records charges you recorded above in “Amount.” You must calculate this figure (if necessary) then supply it to cell H19. 
Any taxes being included are required in the “Tax” cell (H20). 
Finally, take the figure you recorded in “Subtotal” and the one you presented in “Tax.” Add them and place the result as the “Total” owed to the Medical Records Company in cell H21. 
The next cell in this spreadsheet will deal with the timeframe when the Medical Records Company expects its payment sent. The number of “Days that can define this period of tie should be produced in place of the brackets attached to the word “…Days” 
Cell A23 will allow statements or instructions that should be delivered to the Records Keeping Client with this invoice. 
