Invoice Doctor General Practitioner in United States San Francisco –Free Word Template Download with AI
1234 Market Street, Suite 400
San Francisco, CA 94103
United States
Phone: (415) 555-0198
Fax: (415) 555-0199
NPI: 1234567890 | CA Medical License: A123456
INVOICE
Invoice Number: INV-SF-2023-0892Date of Issue: October 24, 2023
Due Date: November 24, 2023
Service Period: October 2023 Bill To (Patient) Mr. Jonathan Doe
567 Valencia Street
Mission District
San Francisco, CA 94110
United States
DOB: 05/12/1985
MRN: 8842-9910 Insurance Information Blue Shield of California
Policy Holder: Jonathan Doe
Group Number: 44556677
Member ID: BS-99887766
Subscriber Phone: (415) 555-0200
| Date of Service | CPT Code | Description of Services | Qty | Unit Price | Total |
|---|---|---|---|---|---|
| Oct 02, 2023 | 99213 | Office Visit - Doctor General Practitioner: Established patient, low complexity medical decision making. Evaluation of persistent cough and fatigue. | 1 | $185.00 | $185.00 |
| Oct 02, 2023 | 87880 | Laboratory Test: Rapid influenza diagnostic test performed in-office. | 1 | $45.00 | $45.00 |
| Oct 15, 2023 | 99214 | Office Visit - Doctor General Practitioner: Established patient, moderate complexity. Follow-up on hypertension management and medication adjustment. | 1 | $245.00 | $245.00 |
| Oct 15, 2023 | 36415 | Phlebotomy: Venipuncture for blood draw (CBC, CMP, Lipid Panel) ordered by General Practitioner. | 1 | $35.00 | $35.00 |
| Oct 20, 2023 | 99203 | New Patient Consultation: Initial comprehensive physical examination and health history review by Doctor General Practitioner. | 1 | $295.00 | $295.00 |
| Oct 20, 2023 | 90471 | Vaccination Administration: Intramuscular injection of Influenza vaccine (Fluzone). | 1 | $25.00 | $25.00 |
| Oct 20, 2023 | 90732 | Vaccine Supply: Influenza virus vaccine, quadrivalent, split virus, preservative free. | 1 | $30.00 | $30.00 |
| Oct 22, 2023 | 99211 | Minor Office Visit: Brief encounter for prescription refill authorization and wound check by nursing staff under supervision of Doctor General Practitioner. | 1 | $75.00 | $75.00 |
| Subtotal (Charges): | $935.00 |
| Insurance Adjustment (Contractual): | ($310.00) |
| Insurance Payment (EOB #445566): | ($425.00) |
| Less: Patient Copay (Collected at Visit): | ($40.00) |
| Patient Responsibility (Due): | $160.00 |
Please make checks payable to "Dr. Elena Rostova, MD".
Mail payments to: 1234 Market Street, Suite 400, San Francisco, CA 94103, United States.
Online payments are accepted via our secure patient portal at www.drostenova-sf.com/pay.
Important Notes:
This Invoice represents the balance due for medical services rendered by a licensed Doctor General Practitioner in accordance with California state regulations and federal billing standards. If you have questions regarding this bill, please contact our billing department at (415) 555-0198 between 8:00 AM and 5:00 PM PST. Late payments may be subject to a 1.5% monthly finance charge. Please include your Invoice Number (INV-SF-2023-0892) and Medical Record Number (MRN) with all correspondence. Authorized By Dr. Elena Rostova, MD
Doctor General Practitioner Patient Acknowledgement Patient Signature / Date ⬇️ Download as DOCX Edit online as DOCX
Create your own Word template with our GoGPT AI prompt:
GoGPT