Invoice Doctor General Practitioner in United States Los Angeles –Free Word Template Download with AI
General Practitioner & Primary Care Physician
1234 Wilshire Boulevard, Suite 500
Los Angeles, CA 90017, United States
Tel: (213) 555-0198 | Fax: (213) 555-0199
Email: [email protected]
NPI: 1234567890 | CA Medical License: A123456
Invoice Number: INV-2023-10-045
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Service Period: October 10, 2023
Bill To:
Patient Name: Jonathan Michael Doe
Address: 789 Sunset Boulevard, Apt 4B
City, State, Zip: Los Angeles, CA 90028, United States
Date of Birth: 05/15/1985
Insurance Provider: Blue Shield of California
Policy Number: BS-9988776655
Group Number: GRP-12345
| Date | CPT Code | Description of Services | Charges | Patient Responsibility |
|---|---|---|---|---|
| 10/10/2023 | 99213 | Office or other outpatient visit for the evaluation and management of an established patient; typically, these visits require 20 minutes of physician time. Includes a detailed history, detailed examination, and moderate complexity medical decision making. | $185.00 | $40.00 |
| 10/10/2023 | 80053 | Comprehensive Metabolic Panel (CMP). This laboratory test measures glucose, calcium, and eight other substances in the blood. Essential for monitoring kidney function, liver function, and electrolyte balance during routine general practice care. | $120.00 | $25.00 |
| 10/10/2023 | 85025 | Complete Blood Count (CBC) with Automated Differential. Analysis of red blood cells, white blood cells, and platelets to screen for various disorders including anemia and infection. | $85.00 | $20.00 |
| 10/10/2023 | 93000 | Electrocardiogram (ECG), routine ECG with at least 12 leads; tracing only, with or without interpretation and report. Performed to assess cardiac rhythm and electrical activity. | $150.00 | $30.00 |
| 10/10/2023 | 90471 | Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injection); each additional vaccine (List separately in addition to code for primary procedure). | $25.00 | $10.00 |
| 10/10/2023 | J0696 | Injection, Tetanus and Diphtheria Toxoids, with or without Pertussis Component, adsorbed, for intramuscular use, 0.5 mL. Administration of booster vaccine as part of preventative care protocol. | $45.00 | $15.00 |
Payment Terms and Important Information:
This Invoice represents the balance due for medical services rendered by Dr. Elena Rostova, a licensed General Practitioner operating within the jurisdiction of Los Angeles, California, United States. As per our office policy and in accordance with California state regulations regarding medical billing, payment is due within 30 days of the invoice date.
Accepted Payment Methods: We accept major credit cards (Visa, MasterCard, American Express), debit cards, personal checks, and cash. For electronic funds transfer (ACH), please contact our billing department at (213) 555-0198.
Insurance Verification: While we have submitted claims to your insurance provider, Blue Shield of California, the amounts listed under "Patient Responsibility" are estimates based on your current plan benefits. You are ultimately responsible for any copayments, deductibles, or coinsurance required by your specific policy. If your insurance coverage changes, please notify our office immediately.
Late Fees: Accounts remaining unpaid after 60 days may be subject to a late fee of 1.5% per month on the outstanding balance, as permitted under California Commercial Code. Persistent non-payment may result in the account being referred to a collection agency, which could negatively impact your credit score.
Disputes: If you believe there is an error on this Invoice, please contact our billing specialist within 15 days of receipt. Please have your Invoice Number (INV-2023-10-045) and Explanation of Benefits (EOB) from your insurance company ready when calling.
Privacy Notice: Your personal health information is protected under the Health Insurance Portability and Accountability Act (HIPAA). This Invoice contains protected health information and should be handled with confidentiality.
Authorized Signature:
Elena Rostova, MD
Dr. Elena Rostova, General Practitioner
Patient Acknowledgement:
By signing below, I acknowledge receipt of this Invoice and agree to the payment terms outlined above.
__________________________
Patient Signature & Date
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