Invoice Doctor General Practitioner in United States Houston –Free Word Template Download with AI
Houston Family Health Associates
1200 Main Street, Suite 400
Houston, TX 77002
United States Houston
Phone: (713) 555-0199
Email: [email protected]
NPI: 1234567890 | TX License: 098765
INVOICE
Billed To (Patient)
Mr. James Anderson
4500 Westheimer Road, Apt 12B
Houston, TX 77027
United States Houston
Date of Birth: 05/12/1985
Phone: (281) 555-0123
Insurance Information
Blue Cross Blue Shield of Texas
Policy Number: BCBS-TX-99887766
Group Number: GRP-HOU-5544
Subscriber: James Anderson
Relationship: Self
Referring Physician: None
| Date | CPT Code | Description of Services | ICD-10 | Qty | Charge |
|---|---|---|---|---|---|
| 10/24/2023 | 99213 | Office or other outpatient visit for the evaluation and management of an established patient; which requires at least two of these three key components: medically appropriate history and/or examination and medical decision making of low complexity. | R51 | 1 | $150.00 |
| 10/24/2023 | 36415 | Collection of venous blood by venipuncture. Performed by Doctor General Practitioner to assess general health markers. | Z00.00 | 1 | $45.00 |
| 10/24/2023 | 80053 | Comprehensive metabolic panel (14 components): bilirubin, total; cholesterol, total; creatinine; glucose; potassium; sodium; carbon dioxide, total; chloride; albumin; protein, total; calcium; and serum enzymes (ALT [SGPT], alkaline phosphatase, and amylase). | Z00.00 | 1 | $120.00 |
| 10/24/2023 | 85025 | Complete blood count (CBC) with automated differential. Essential screening for a Doctor General Practitioner in Houston. | Z00.00 | 1 | $85.00 |
| 10/24/2023 | 90471 | Immunization administration via any route (includes percutaneous, intradermal, subcutaneous, or intramuscular injection); 1-2 vaccine/toxoid components. | Z23 | 1 | $35.00 |
| 10/24/2023 | 90658 | Influenza, seasonal, injectable, preservative free. Administered during routine check-up. | Z23 | 1 | $25.00 |
| 10/24/2023 | 99211 | Office or other outpatient visit for the evaluation and management of an established patient; which may not require the presence of a physician or other qualified health care professional. | Z79.899 | 1 | $50.00 |
| Subtotal: | $510.00 |
| Insurance Adjustment (Est.): | -$210.00 |
| Insurance Payment (Est.): | -$200.00 |
| Patient Responsibility: | $100.00 |
Payment Instructions & Important Notes
This Invoice represents the financial statement for medical services rendered by Dr. Elena Rodriguez, a licensed Doctor General Practitioner, located in United States Houston. Please review the charges carefully.
Payment Methods Accepted:
- Online Payment: Please visit our secure patient portal at portal.houstonfamilyhealth.com to pay this invoice using a credit card or bank transfer.
- Mail: Send checks or money orders payable to "Houston Family Health Associates" to the address listed in the header.
- In-Person: Payments can be made at our front desk during business hours (Monday-Friday, 8:00 AM - 5:00 PM CST).
Insurance Claims: We have submitted the primary claim to your insurance provider. The amounts listed above are estimates based on your plan's benefits. If your insurance processes differently, a credit or additional balance may be adjusted within 30 days.
Late Fees: As per our practice policy in Houston, Texas, accounts unpaid after 60 days from the date of this invoice may be subject to a late fee of 1.5% per month or may be referred to a collection agency.
Questions? If you have any questions regarding this invoice or the services provided by your Doctor General Practitioner, please contact our billing department at (713) 555-0199 ext. 202.
Authorized Signature
Dr. Elena Rodriguez, MD
Doctor General Practitioner
Patient Acknowledgement
I acknowledge receipt of this invoice.
Date: _________________
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