Invoice Doctor General Practitioner in Israel Jerusalem –Free Word Template Download with AI
12 King George Street
Jerusalem, 9410101
Israel Jerusalem
Tel: +972-2-555-1234
Email: [email protected]
VAT Registration Number: 501234567
Medical License No: 12345-6789
Clalit Health Services Provider ID: CLT-98765
INVOICE
Invoice Number: INV-2024-0892
Date of Issue: October 15, 2024
Date of Service: October 10, 2024
Due Date: November 15, 2024
Payment Status: Pending
Billed To (Patient)
Mr. David Levi
45 Rehov HaYehudim
Jerusalem, 9410101
Israel Jerusalem
ID Number: 123456789
Phone: +972-50-123-4567
Email: [email protected]
Insurance Information
Provider: Maccabi Healthcare Services
Policy Number: MAC-789456123
Group Number: GRP-456789
Pre-authorization: AUTH-2024-5678
Referral Required: Yes (Provided)
Medical Services Rendered
The following services were provided by Dr. Sarah Cohen, Doctor General Practitioner, at our clinic located in Israel Jerusalem. All procedures comply with the standards set by the Israeli Ministry of Health and the Israel Medical Association.
| # | Description of Service | ICD-10 Code | Quantity | Unit Price (ILS) | Total (ILS) |
|---|---|---|---|---|---|
| 1 |
Comprehensive General Practice Consultation Initial assessment and diagnosis by Doctor General Practitioner. Includes medical history review, physical examination, and preliminary treatment plan. Conducted at our Jerusalem clinic. |
Z00.00 | 1 | 350.00 | 350.00 |
| 2 |
Follow-up Consultation Subsequent visit to monitor patient progress and adjust treatment. Doctor General Practitioner reviewed symptoms and updated medication regimen. |
Z09 | 1 | 250.00 | 250.00 |
| 3 |
Blood Pressure Monitoring & Cardiovascular Screening Routine screening performed by Doctor General Practitioner to assess cardiovascular health. Includes ECG interpretation. |
R03.0 | 1 | 180.00 | 180.00 |
| 4 |
Laboratory Test Coordination & Interpretation Doctor General Practitioner ordered and interpreted comprehensive blood panel (CBC, metabolic panel, lipid profile). Tests conducted at accredited lab in Israel Jerusalem. |
R79.89 | 1 | 420.00 | 420.00 |
| 5 |
Prescription Management & Medication Counseling Doctor General Practitioner provided detailed counseling on prescribed medications, potential side effects, and interactions. Includes electronic prescription submission to pharmacy. |
Z79.899 | 1 | 150.00 | 150.00 |
| 6 |
Health Education & Preventive Care Counseling Doctor General Practitioner provided personalized advice on lifestyle modifications, nutrition, and preventive health measures specific to patient's condition. |
Z71.3 | 1 | 200.00 | 200.00 |
| 7 |
Medical Certificate Issuance Official medical certificate prepared by Doctor General Practitioner for employer/insurance purposes. Includes official clinic stamp and signature. |
Z02.9 | 1 | 100.00 | 100.00 |
| 8 |
Administrative & Record Keeping Fees Documentation of medical records, insurance claim preparation, and communication with referring specialists in Israel Jerusalem healthcare network. |
Z00.00 | 1 | 75.00 | 75.00 |
Important Notes & Payment Instructions
Payment Methods: This Invoice may be paid via bank transfer, credit card, or cash at our clinic in Israel Jerusalem. For bank transfers, please use the following details:
Bank: Bank Hapoalim
Branch: Jerusalem Central
Account Name: Dr. Sarah Cohen Medical Services Ltd.
Account Number: 987654321
SWIFT Code: POALILIT
Reference: INV-2024-0892
Insurance Claims: This Invoice has been submitted to your insurance provider. The amount due represents the patient's co-payment responsibility after insurance coverage. Please retain this document for your records.
Late Payment: Payments not received by the due date may be subject to a late fee of 1.5% per month, in accordance with Israeli commercial law.
Medical Records: All medical records related to these services are maintained at our clinic in Israel Jerusalem and are accessible to the patient upon request, in compliance with the Israeli Privacy Protection Law.
Contact: For any questions regarding this Invoice or the services provided by our Doctor General Practitioner, please contact our office at +972-2-555-1234 or visit us at 12 King George Street, Jerusalem, Israel Jerusalem.
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