Invoice Doctor General Practitioner in Chile Santiago –Free Word Template Download with AI
Consultorio Médico Providencia
Av. Providencia 1234, Oficina 502
Santiago, Región Metropolitana, Chile
RUT: 12.345.678-9
Email: [email protected]
Phone: +56 2 2345 6789
INVOICE
Invoice Number: INV-2023-10-045
Date of Issue: October 24, 2023
Due Date: November 07, 2023
Service Period: October 2023
Bill To:
Paciente: Maria Elena Soto
RUT: 15.678.901-K
Address: Calle Las Acacias 450, Depto 101
Santiago, Chile
Isapre/Health Fund: Isapre Colmena
Policy Number: 987654321
Legal & Banking Details:
Bank: Banco de Chile
Account Type: Current Account
Account Number: 1234567890123
CLABE/RUT: 12.345.678-9
Reference: Invoice INV-2023-10-045
| # | Description of Medical Services | Date | Quantity | Amount (CLP) |
|---|---|---|---|---|
| 1 |
General Practitioner Consultation (Initial) Comprehensive medical evaluation including anamnesis, physical examination, and preliminary diagnosis. Conducted at the Santiago clinic. |
Oct 02, 2023 | 1 | $45.000 |
| 2 |
Follow-up Consultation Review of diagnostic results and adjustment of treatment plan. |
Oct 15, 2023 | 1 | $35.000 |
| 3 |
Medical Certificate Issuance Official documentation for employment purposes regarding temporary medical leave. |
Oct 03, 2023 | 1 | $15.000 |
| 4 |
Administrative Fee for Isapre Reimbursement Processing of medical records and formal invoice generation for health insurance claim. |
Oct 24, 2023 | 1 | $10.000 |
Amount in words: One hundred twenty-four thousand nine hundred fifty Chilean Pesos.
Terms and Conditions:
1. This Invoice is issued in accordance with the regulations of the Servicio de Impuestos Internos (SII) of Chile.
2. Payment is due within 15 days from the date of issue. Late payments may incur a penalty interest rate of 1.5% per month.
3. This document serves as proof of payment for services rendered by the Doctor General Practitioner. Please retain this copy for your personal records and for submission to your Isapre or Fonasa for reimbursement purposes.
4. All medical services were performed in compliance with the ethical standards of the Colegio Médico de Chile.
5. For any discrepancies regarding this invoice, please contact the administrative office in Santiago within 5 business days.
6. This invoice is valid for tax deduction purposes for the fiscal year 2023.
Authorized Signature
Dr. Alejandro Valenzuela
Doctor General Practitioner
RUT: 12.345.678-9
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