Invoice Doctor General Practitioner in United States Miami –Free Word Template Download with AI
1200 Brickell Avenue, Suite 400
Miami, Florida 33131
United States
Phone: (305) 555-0199
Email: [email protected]
NPI: 1234567890 | FL License: XM1234567
INVOICE
Billed To (Patient)
Mr. James Anderson
4500 SW 8th Street, Apt 3B
Miami, Florida 33134
United States
Date of Birth: 05/12/1985
Phone: (305) 555-0123
Insurance Information
Blue Cross Blue Shield of Florida
Policy Holder: James Anderson
Member ID: BCBS-FL-99887766
Group Number: GRP-445566
PCP Authorization: Approved
| Code | Description of Services | Date | Units | Charges | Patient Responsibility |
|---|---|---|---|---|---|
| 99213 | Office Visit - Established Patient (General Practitioner Consultation) | 10/20/2023 | 1 | $180.00 | $40.00 |
| 80053 | Comprehensive Metabolic Panel (Blood Work Analysis) | 10/20/2023 | 1 | $150.00 | $30.00 |
| 85025 | Complete Blood Count (CBC) with Differential | 10/20/2023 | 1 | $95.00 | $20.00 |
| 93000 | Electrocardiogram (ECG) - Routine 12-Lead | 10/20/2023 | 1 | $120.00 | $25.00 |
| 36415 | Collection of Venous Blood by Venipuncture | 10/20/2023 | 1 | $45.00 | $10.00 |
| 99214 | Follow-up Visit - Management of Chronic Condition | 10/24/2023 | 1 | $220.00 | $50.00 |
| J3490 | Prescription Medication Administration (In-Office) | 10/24/2023 | 1 | $65.00 | $15.00 |
| Total Billed Charges: | $875.00 |
| Insurance Adjustment: | ($450.00) |
| Insurance Payment Applied: | ($305.00) |
| Less Previous Payments: | $0.00 |
| TOTAL AMOUNT DUE: | $190.00 |
Payment Instructions & Important Information
This Invoice represents the outstanding balance for medical services rendered by Dr. Elena Rodriguez, a licensed General Practitioner, at our clinic located in Miami, Florida. As per the regulations of the United States healthcare system and your specific insurance policy, the amounts listed above reflect the patient's financial responsibility after insurance adjudication.
Payment Methods: We accept payments via credit card (Visa, MasterCard, Amex), debit card, personal check, or bank transfer. Online payments can be made securely through our patient portal at portal.miamicoastalmd.com.
Due Date: Payment is due within 30 days of the invoice date. Please include the Invoice Number (INV-2023-10-8842) with your payment to ensure proper application to your account.
Disputes: If you believe there is an error on this invoice, please contact our billing department in Miami immediately at (305) 555-0199. Please have your insurance card and this invoice number ready.
Privacy Notice: In accordance with HIPAA regulations in the United States, your medical and billing information is kept strictly confidential.
Authorized By:
Dr. Elena Rodriguez, MD
General Practitioner
Patient Acknowledgement:
I acknowledge receipt of this invoice and understand my financial responsibility.
Signature: __________________________
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