A medical billing questionnaire is a questionnaire which is used in medical centers or hospitals to take the billing details of a patient. These questionnaires are very effective to have a written record of the medical receipts and bills for the hospital. A medical billing questionnaire has multiple questions which are asked from patients or the family member of the patients to inquire about the medical procedures which the patient has undergone. Given below is a sample of a medical billing questionnaire which can be used by any person for the sake of reference.

Sample Medical Billing Questionnaire:

Name of the patient:

Age of the patient:

Gender of the patient:

Name of parent/guardian/family member:

Residential address of the patient:

Contact number of the patient:

Email address of the patient:

Contact number of parent/guardian/family member:

Kindly fill in all the details and answer all the following given questions to help us complete your medical billing procedure.

Q1. Since when have you been admitted in this hospital? Give the date.


Q2. What was the medical condition due to which you were admitted in the hospital?

a)      Fracture

b)      Infection

c)      Heart condition

d)     Lung condition

e)      Dental condition

f)       Liver condition

g)      Allergy

h)      Dengue

i)        Jaundice

j)        Other(please specify)

Q3. What was the total billing amount of the treatment?


Q4. Did you incur any other medical charges?

a)      Yes

b)      No

Q5. If yes, then please give the figure of the additional charges.


Q6. What is your method of payment?

a)      Cash

b)      Credit card

c)      Debit card

Q8. If you have selected b) or c) option, then which card would you be paying from?

a)      MasterCard

b)      Visa

c)      American express

Q9. Are you medically insured?

a)      Yes

b)      No

Q10. Have you produced your insurance documents?

a)      Yes

b)      No