Spreadsheet: 179476d1347275431-error-when-applying-formula-to-other-cells-ef185_occupational-theraphy
Sheet: Sheet1

STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
DR DWH TERRY AND ASSOCIATED INC. |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: | Fill In | Tell : | Fill In
 |  | Fax : |  |  | File Ref: | Fill In | Cell: | Fill In
 |  | [NAME] No : |  |  |  |  | Fax : | Fill In
 |  | Account Queries: |  |  | Email : | Fill In
 |  | Tell :
 |  | Email : |  |  | Patient | Fill In
 |  |  |  |  | Address | Fill In
 |  |  |  |  |  | Fill In
 |  |  |  |  |  | Fill In
 |  |  |  |  |  | Fill In
Date | Details |  |  |  |  |  | Amount | Paid | [NAME]
 | Patient : | Fill In |  | ID No : | Fill In
 | DOB : | Fill In
 | Treating Provider : |  | Fill In
 | ICD-10/Diagnoses :
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB : |  | Treat. Prov:
 | ICD-10/Diagnoses :
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax : | Fill In
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Details |  |  |  |  |  | Amount | Total | Inv. Total
 | Patient : |  |  | ID No :
 | DOB :
 | Treating Provider(s) : |  | Fill In
 | ICD-10 :  Fill In
 | Procedure(s) / Modifiers
1
2
3
4
5
6
 | ICD-10 : |  |  | Treating Provider :
1
2
3
4
5
6
 |  |  |  |  |  | *all amounts include VAT
 |  | Invoice Amount Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
STATEMENT
Invoice No: 1 |  |  |  |  |  |  |  | Date:
 |  |  |  |  | PATIENT DETAILS (Office Only)
 |  | Pr No :
 |  | Tell : |  |  | Acc. No: |  | Tell :
 |  | Fax : |  |  | File Ref: |  | Cell:
 |  | [NAME] No : |  |  |  |  | Fax :
 |  | Account Queries: |  |  | Email :
 |  | Tell :
 |  | Email : |  |  | Patient
 |  |  |  |  | Address
Date | Consulation Details |  | Amount | Date | Pymt. [NAME]. | Payment Detials |  | Receipt No. | Amount
 |  | Total Due |  |  |  | Total
Attention to Account Holder |  |  |  |  |  |  | Acc. Start | Acc. Current | Acc. Age
Account Queries:
*All amounts Incl. VAT.
 |  | Total Account Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :
Date | Consulation Details |  | Amount | Date | Pymt. [NAME]. | Payment Detials |  | Receipt No. | Amount
 |  | Total Due |  |  |  | Total
Attention to Account Holder |  |  |  |  |  |  | Acc. Start | Acc. Current | Acc. Age
Account Queries:
*All amounts Incl. VAT. |  |  |  | * Amounts due are labled as e.g. 100 & Credit Amounts are labled as e.g. -100
 |  | Total Account Due |  | 90 Days + | 60 Days | 30 Days | Current | Total | Acc. Total*
EFT Banking Details
Acc. Holder: |  |  | Account No. |  |  | Reference for Practice :
Bank Name: |  |  | Branch Code |  |  | Branch Name :