Payment status:
Paid
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Wellness First Family Practice
License #: NPI-1234567890
(555) 555-0100
mike@spark-electric.linkconomy.com
420 Medical Center Blvd Suite 305
RECEIPT
REC-MUDAKJ
Sep 25, 2026
PaidBill To:
(Sample) Carol Henderson
carol.henderson@email.test
(555) 204-0001
| Service | Date | Amount | Tax | Total |
|---|---|---|---|---|
|
Annual Wellness Exam
Preventive health screening and exam
|
Sep 25, 2026 | $175.00 | $14.00 (8.00%) | $189.00 |
|
Chronic Care Management
Diabetes, hypertension, thyroid management
|
Sep 25, 2026 | $150.00 | $12.00 (8.00%) | $162.00 |
Subtotal:
$325.00
Tax:
$26.00
Total:
$351.00