Invoice Doctor General Practitioner in Philippines Manila –Free Word Template Download with AI
Makati Medical Center Annex
123 Ayala Avenue Corner McKinley Road
Makati City, Metro Manila, Philippines 1226
Tel: +63 (2) 8888-1234 | Mobile: +63 917-555-0199
Email: [email protected]
Invoice #: INV-2023-10-045
Date Issued: October 24, 2023
Due Date: November 24, 2023
Billed To (Patient)
Mr. Juan Dela Cruz
456 Barangay San Antonio
Quezon City, Metro Manila, Philippines 1100
Contact: +63 918-123-4567
Email: [email protected]
Insurance / HMO Details
Provider: Maxicare Health Maintenance Organization
Policy Number: MC-9988776655
Group ID: G-12345678
Plan Type: Gold Plan (Outpatient Coverage)
Authorization Code: AUTH-2023-8899
Medical Services Rendered
The following charges reflect the professional fees and diagnostic services provided by Dr. Elena Santos, a licensed General Practitioner in the Philippines, during the consultation held on October 24, 2023, at the Manila clinic.
| # | Description of Service | ICD-10 / CPT Code | Quantity | Unit Price (PHP) | Total (PHP) |
|---|---|---|---|---|---|
| 1 |
Initial Office Visit - General Practitioner Consultation Comprehensive evaluation of patient history, physical examination, and diagnosis for acute upper respiratory infection. Includes discussion of treatment plan and medication prescription. |
Z00.00 / 99203 | 1 | 2,500.00 | 2,500.00 |
| 2 |
Diagnostic Laboratory Referral - Complete Blood Count (CBC) Order and interpretation of CBC to assess white blood cell count and infection markers. Performed at partner lab in Manila. |
85025 | 1 | 1,200.00 | 1,200.00 |
| 3 |
Rapid Strep Test Point-of-care testing for Group A Streptococcus bacteria to confirm bacterial infection. |
87180 | 1 | 850.00 | 850.00 |
| 4 |
Medical Certificate Issuance Official documentation for employer regarding sick leave (3 days) as per Philippine Labor Code standards. |
Admin | 1 | 500.00 | 500.00 |
| 5 |
Prescription Medication Consultation Detailed review of prescribed antibiotics and symptomatic relief medications, including dosage instructions and potential side effects. |
99211 | 1 | 300.00 | 300.00 |
Payment Methods
Payments can be made via the following methods accepted in Manila:
- Bank Transfer: BDO Unibank, Account Name: Dr. Elena Santos, Account No: 1234-5678-9012
- GCash / Maya: +63 917-555-0199
- Credit Card: Visa/Mastercard accepted via secure online portal
- Cash: Accepted at the clinic during office hours
Terms and Conditions
1. This invoice is issued in accordance with the regulations of the Philippine Medical Association and the Bureau of Internal Revenue (BIR).
2. Payment is due within 30 days from the date of issue. Late payments may incur a 1.5% monthly interest charge.
3. HMO claims must be submitted within 60 days of the service date. Please ensure all required documents are attached.
4. For questions regarding this invoice, please contact our billing department at [email protected] or call +63 (2) 8888-1234 ext. 105.
5. This document serves as an official receipt for tax purposes in the Philippines.
Authorized Signature:
Dr. Elena Santos, MDGeneral Practitioner
PRC License No: 123456
MPA ID: 987654 ⬇️ Download as DOCX Edit online as DOCX
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