Itemized Medical Bill Request Log PDF
Track requests for itemized bills (dates, contact, status).
Track itemized bill requests
Record request dates, contacts, delivery methods, and follow-up status.
Status message placeholder
Empty values allowed. Narrow table layout only.
| Date Requested | Provider / Facility | Billing Department Contact | Account / Invoice # | Delivery Method | Status | Notes | Actions |
|---|---|---|---|---|---|---|---|
No parsing or calculations. Export exactly what you type.
🔒 MANDATORY CODEX SAFETY FOOTER (INCLUDE VERBATIM)
Non-Negotiable Guardrails
- Do not modify global layout, header, footer, ads, analytics, or shared components
- Do not import @/components/ui/select or any unverified shadcn components
- Use native HTML inputs only
- Row add/remove buttons must be plain <button>
- No date math, no parsing, no calculations
- PDF builders must return Promise<Uint8Array>
- Always create Blobs using bytesToPdfBlob(bytes) from lib/pdf/bytes.ts
- Never include null in React-PDF style arrays
- No refactors
- Tool may only break itself