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6 Templates

Healthcare Receipt Templates

Healthcare receipts document medical visits, procedures, prescriptions, and out of pocket charges. They are commonly used for FSA and HSA reimbursements, insurance claims, and tax records. A typical medical receipt includes patient name, visit date, provider name, procedure codes, charges, insurance adjustments, and amount due. Our collection has 6 customizable templates from brands like Aetna, Blue Cross Blue Shield, Cigna, and Cleveland Clinic, each fully editable. Update line items, prices, dates, and store information to match what you need, then download the receipt as a PNG image.

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151 Farmington Ave Hartford, CT 06156
1-800-872-3862
Premium Payment Receipt
Member: David Chen
Member ID: AET-4829103-01
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02/01/2026, 12:00 AM
Plan:Aetna Gold PPO
Coverage Period:Feb 2026
Group #:00817432
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Medical Premium$412.00
Dental Premium$38.50
Vision Premium$12.75
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Subtotal$463.25
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Total$463.25
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ACH/Bank Draft****8847
Amount$463.25
Confirmation #AET20260201
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Next payment due: 03/01/2026 View your benefits at aetna.com/member or call 1-800-872-3862 Thank you for choosing Aetna.

Aetna Receipt

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225 N. Michigan Ave Chicago, IL 60601
1-800-521-2227
Premium Payment Receipt
Subscriber: Maria Gonzalez
ID: XYZ987654321
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02/01/2026, 12:00 AM
Plan:BCBS PPO Silver
Dependents:2
Coverage:Feb 2026
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Family Medical Premium$895.00
Dental Plus Coverage$55.00
Vision Rider$18.50
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Subtotal$968.50
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Total$968.50
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ACH Draft****3302
Amount$968.50
Auth #BCBS20260201
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Next payment due: 03/01/2026 Find a doctor at bcbs.com or call 1-800-521-2227 Thank you for choosing BCBS.

Blue Cross Blue Shield Receipt

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900 Cottage Grove Rd Bloomfield, CT 06002
1-800-997-1654
Explanation of Benefits
Member: James Patel
Member ID: U19204837201
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02/01/2026, 12:00 AM
Plan:Cigna Connect 2500
Period:Feb 2026
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Individual Medical Premium$348.00
Pharmacy Benefit$28.00
Behavioral Health Rider$15.50
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Subtotal$391.50
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Total$391.50
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ACH Debit****9910
Amount$391.50
Ref #CGN20260201
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Next payment: 03/01/2026 Mycigna.com for benefits or call 1-800-997-1654 Thank you for choosing Cigna.

Cigna Receipt

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9500 Euclid Avenue Cleveland, OH 44195
1-800-223-2273
Patient Statement
Patient: Robert Williams
Account #: CC-9281047
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02/18/2026, 10:30 AM
Provider:Dr. S. Nguyen, MD
Dept:Cardiology
Ref #:ENC20260218-4892
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Office Visit (Level 4)$320.00
EKG Interpretation$85.00
Lab: Lipid Panel$45.00
Insurance Adjustment$-215.00
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Subtotal$235.00
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Total$235.00
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Visa****4418
Patient Copay$235.00
Balance Due$0.00
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View your health records at mychart.clevelandclinic.org Questions? Call 1-800-223-2273 Thank you for trusting Cleveland Clinic.

Cleveland Clinic Receipt

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500 W. Main Street Louisville, KY 40202
1-800-486-2620
Premium Payment Receipt
Member: Betty Morrison
Member ID: H22948301
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02/01/2026, 12:00 AM
Plan:Humana Gold Plus HMO
Type:Medicare Advantage
Period:Feb 2026
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Medicare Advantage Premium$0.00
Part B Premium (deducted SSA)$185.00
Dental/Vision/Hearing Rider$39.00
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Subtotal$224.00
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Total$224.00
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ACH Draft****6621
Amount$224.00
ConfirmationHUM20260201
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Next payment: 03/01/2026 humana.com/member-portal or call 1-800-486-2620 (TTY: 711) Thank you for choosing Humana.

Humana Receipt

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200 First St. SW Rochester, MN 55905
1-507-284-2511
Patient Statement
Patient: Linda Hartmann
Patient #: MC-7736201
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02/20/2026, 09:00 AM
Provider:Dr. A. Larsen, MD
Dept:Neurology
Visit #:VIS20260220-1182
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New Patient Consult$550.00
MRI Brain w/o Contrast$1200.00
Neuropsych Screening$180.00
Insurance Adjustment$-1350.00
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Subtotal$580.00
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Total$580.00
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Mastercard****2271
Patient Balance$580.00
Amount Paid$580.00
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Access your records at mayoclinic.org/patient-portal Questions: 1-507-284-2511 The needs of the patient come first.

Mayo Clinic Receipt

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