Printable hospital template
Hospital bill adjustment authorisation record
Record the reason and authority for a hospital bill correction, preserve the original reference and check the resulting balance after the change.
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- RizCare
- Published
- Last reviewed
RizCare's suggested worksheet. Adapt to your hospital. https://riz.care/library/templates/clinic-bill-adjustment-authorisation
For the practice manager and authorised billing staff.
The same service appears twice on an invoice. The patient has raised the question, and staff have checked the supporting record. The next step is an authorised decision about the bill, with enough detail for another staff member to follow it.
Keep the investigation in the billing query log. This record starts when a specific adjustment is proposed and follows that proposal through approval and completion.
Print this page or save it as a PDF from your browser. The print layout contains only the blank worksheet and its completion note. Fill it in within your hospital.
Practice: ____________________ Prepared by: ____________________ Date: ______________
| Query / invoice | Proposed change | Decision / authority | Correction reference | Checked balance |
|---|---|---|---|---|
| Blank entry | ||||
| Blank entry | ||||
| Blank entry | ||||
| Blank entry | ||||
| Blank entry |
Keep completed copies with the staff authorised to use them.
How to use it
Describe the exact change
Identify the invoice, the affected line and the reason supported by the investigation. Record the amount before the proposed adjustment and the expected amount afterwards. Describe whether the issue concerns a duplicate charge, an incorrect price or another documented cause. Reception should not infer that a service was unnecessary from a billing disagreement.
Obtain an actual decision
Name the person authorised under the hospital's policy to decide this type of adjustment. Record approved, declined or awaiting information, with the date and reason. A patient's request and a manager's approval are separate events. If the decision changes, retain the earlier instruction and document the replacement clearly.
Check the corrected position
The staff member making the permitted correction records its reference, then a reviewer compares the resulting bill with the authorised instruction. Preserve the original history and the patient's existing payment entries. A lower bill may raise a separate question about money already received; do not label that difference refunded until the hospital's authorised refund procedure has actually been completed.
What each field means
- Proposed amount
- State the amount being changed and the expected bill total afterwards. A minus sign without an explanation can be read as either a reduction or an amount owed.
- Authority
- Use the real approver name or staff identifier and decision date. Leave approval blank while the request is awaiting a response.
- Completion check
- Record the correction reference, resulting balance and checker. Tell the responsible colleague if the software cannot perform the approved action without losing history.
Completed fictional example
The fictional duplicate was removed through an authorised correction. No refund is represented by this row.
| Query / invoice | Proposed change | Decision / authority | Correction reference | Checked balance |
|---|---|---|---|---|
| Q-11 / INV-085 | Remove duplicate 5,000-naira line | Approved / Manager A | COR-09 | 5,000 naira due / Staff B |
Related resources
Sources and review
The worksheet design and examples are RizCare's recommendations. The sources below support the background discussion; they do not endorse this form.
- Bookkeeping and financial management training manual (FAO-hosted Liberia forestry training resource). Read 9 September 2026.