Willowbrook Family Clinic
3100 Wellness Way, Suite 210
Raleigh, NC 27607
(919) 555-0140 · billing@willowbrook.example
willowbrook.example
NPI 1000000000
Patient Statement
INV-1048
Amount due
$110.60
Due date
Nov 15, 2026
Bill to
Samuel Reyes
92 Cedar Hollow Rd
Cary, NC 27513
sreyes@mail.example · (919) 555-0175
Patient
Patient
Samuel Reyes
Date of service
Oct 9, 2026
Provider
Dr. Lena Okoro, MD
Items
| Description | Qty | Rate | Amount |
|---|---|---|---|
| Office visit, established patient (99214) | 1 | $185.00 | $185.00 |
| Venipuncture (36415) | 1 | $22.00 | $22.00 |
| Insurance adjustment — BlueRiver PPO | 1 | −$96.40 | −$96.40 |
Notes
Thank you for your business.
Terms
Balance due within 30 days. Please contact our billing office with any insurance questions.
Payment
Pay by ACH, card or check. Please include the invoice number with your payment.
Due Nov 15, 2026 · $110.60
Authorization
Customer signature
Date