Invoice Midwife in United States Chicago –Free Word Template Download with AI
1234 Lake Shore Drive, Suite 400
Chicago, IL 60611, United States
Phone: (312) 555-0199 | Email: [email protected]
Tax ID: 36-XXXXXXX
Invoice Number: INV-2023-10-8842
Date Issued: October 24, 2023
Due Date: November 24, 2023
Payment Status: Pending
Bill To:
Client Name: Sarah & Michael Johnson
Address: 5678 Lincoln Avenue
City, State, Zip: Chicago, IL 60614, United States
Phone: (773) 555-0123
Email: [email protected]
Insurance Provider: Blue Cross Blue Shield of Illinois
Policy Number: BCBS-IL-99887766
Service Summary:
Attending Midwife: Elena Rodriguez, CNM
Service Type: Comprehensive Outpatient Midwifery Care
Period of Service: August 1, 2023 - September 30, 2023
Location: Windy City Midwifery Clinic, Chicago, IL
| # | Description of Midwifery Services | CPT Code | Quantity | Amount (USD) |
|---|---|---|---|---|
| 1 | Initial Comprehensive Prenatal Assessment and History Taking. Includes physical examination, risk assessment, and establishment of care plan tailored to Chicago health standards. | 99203 | 1 | $350.00 |
| 2 | Monthly Prenatal Visits (August). Routine monitoring of fetal development, maternal blood pressure checks, urine analysis, and nutritional counseling provided by licensed midwife. | 99213 | 4 | $800.00 |
| 3 | Monthly Prenatal Visits (September). Continued obstetric care, including growth scans coordination and preparation for birth planning in Chicago area facilities. | 99213 | 4 | $800.00 |
| 4 | Laboratory Services Coordination. Ordering and interpretation of blood work, genetic screening, and infectious disease testing required for prenatal care in Illinois. | 80048 | 1 | $250.00 |
| 5 | Patient Education Session. Group workshop on childbirth preparation, breastfeeding basics, and newborn care held at our Chicago clinic. | 98966 | 2 | $200.00 |
| 6 | Ultrasound Interpretation. Review of anatomical survey ultrasound results to ensure fetal well-being and proper development. | 76801 | 1 | $150.00 |
| 7 | Administrative Fee. Processing of insurance claims, medical records management, and coordination with pediatricians in the United States Chicago metropolitan area. | 99024 | 1 | $75.00 |
Payment Instructions & Important Notes
Payment Methods: We accept payments via credit card (Visa, MasterCard, Amex), bank transfer (ACH), or personal check. Please make checks payable to "Windy City Midwifery Collective."
Bank Transfer Details:
Bank Name: Chicago Community Bank
Account Name: Windy City Midwifery Collective
Routing Number: 071000013
Account Number: 9876543210
Reference: Invoice #INV-2023-10-8842
Insurance Information: This invoice reflects services rendered by a Certified Nurse Midwife (CNM) in accordance with Illinois state regulations. We have submitted claims to your primary insurance provider. The "Insurance Adjustment" represents the estimated amount covered by your plan. You are responsible for any co-pays, deductibles, or non-covered services as outlined in your policy. Please contact our billing department if you have questions about your coverage.
Late Payment Policy: Payments are due within 30 days of the invoice date. A late fee of 1.5% per month will be applied to balances remaining unpaid after the due date. Persistent non-payment may result in the suspension of further midwifery services.
Disputes: If you believe there is an error on this invoice, please contact us within 10 business days of receipt. Please provide the invoice number and a detailed explanation of the discrepancy.
Authorized Signature:
Elena Rodriguez, CNM
Lead Midwife & Billing Manager
Windy City Midwifery Collective
Client Acknowledgement:
__________________________
Signature
Date: ______________
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