CheckoutReceipt is for legitimate business, creative, and educational use only. Generating receipts to commit fraud or deceive others is prohibited — see our Terms of Service.

Sick Visit

Generate Your Own Receipt

Free, no signup required. Customize every line item, total, store name, and date.

Create Sick Visit Receipt

Choose from 100+ receipt formats

Sick Visit Receipt Example

This receipt documents a sick visit at Lakeview Medical Associates with two billed services: a CPT 99213 office visit ($165.00) and a CPT 87400 rapid influenza test ($55.00). The combined billed amount of $220.00 is reduced by a $78.40 contractual adjustment to an allowed amount of $141.60. Aetna paid $111.60, leaving a $30.00 copay as the patient's only out-of-pocket cost.

This sick visit receipt documents an established-patient office visit (CPT 99213) for acute upper respiratory infection (ICD-10 J06.9), billed at $185 with $135 insurance adjustment and $30 patient copay. The receipt shows the provider NPI, diagnosis code, and FSA/HSA-eligible flag.

Receipt Breakdown

CPT 99213: Office Visit, Established Patient (Level 3)$165.00
CPT 87400: Influenza Antigen Test (Rapid)$55.00
Total Billed$220.00
Contractual Adjustment−$78.40
Allowed Amount$141.60
Insurance Paid (Aetna HMO)−$111.60
Patient Copay$30.00
ICD-10J11.1

What Makes This Receipt Realistic

  • • Two CPT codes on one receipt, office visit and in-office test billed separately
  • • ICD-10 J11.1: influenza diagnosis code linking to both services
  • • Single $30.00 copay covers both the visit and the flu test
  • • CPT 87400 billed at $55.00, realistic rapid flu test billed amount
  • • Math: $220.00 − $78.40 = $141.60 allowed; $141.60 − $111.60 = $30.00 copay
Customize This Template →

More Doctor Visit Examples

General Checkup Receipt

CPT 99213 single visit with $30.00 copay: $30.00

Urgent Care Receipt

Higher urgent care copay tier: $75.00

← All doctor visit examples← All examples

Frequently Asked Questions

What does this sick visit receipt show?

This receipt documents a sick visit at Lakeview Medical Associates, 3200 N. Sheridan Rd, Chicago, IL 60657. Patient: Maria E. Castillo. Date of Service: October 14, 2025. Two service lines: CPT 99213: Office Visit, Established Patient, Level 3 ($165.00 billed) and CPT 87400: Influenza Antigen Test ($55.00 billed). Total Billed: $220.00. Contractual Adjustment: −$78.40. Allowed Amount: $141.60. Insurance Paid (Aetna HMO): −$111.60. Patient Copay: $30.00. ICD-10: J11.1 (Influenza with other respiratory manifestations). HSA/FSA Eligible.

Why does a sick visit receipt show two CPT codes?

When a doctor performs both an office visit and an in-office diagnostic test, each service is billed separately under its own CPT code. CPT 99213 covers the physician's time evaluating and examining the patient. CPT 87400 covers the influenza antigen (rapid flu) test performed using a nasal swab processed in the office. Both appear on the same receipt as separate line items because they represent distinct services. The patient typically pays a single copay that covers all services rendered during that visit, rather than separate copays for each CPT code line.

Does the office visit copay cover the flu test or is there a separate charge?

Under most insurance plans, a single office visit copay covers all services rendered during that visit, including in-office lab tests like a rapid flu test, strep test, or urinalysis. You pay one $30.00 copay regardless of whether the doctor runs one test or three. The flu test line appears on the receipt as a separate billed charge, but it is absorbed into the insurance payment alongside the office visit, only the copay remains as patient responsibility. Some high-deductible plans and certain plan designs may charge separately for in-office tests; check your Explanation of Benefits for details.