Invoice Midwife in United States Houston –Free Word Template Download with AI

Bill To:

Sarah J. Thompson

456 Oak Forest Drive

Houston, Texas 77024, United States

Phone: (832) 555-0144

Email: [email protected]

Insurance / Payment Info:

Provider: Blue Cross Blue Shield of Texas

Policy Number: BCBS-TX-99887766

Group Number: GRP-445566

Member ID: MEM-11223344

#	Description of Midwifery Services	Date of Service	CPT Code	Quantity	Unit Price	Total
1	Initial Comprehensive Prenatal Assessment & Care Plan Development. Includes medical history review, physical examination, and establishment of birth preferences in accordance with Texas Board of Nursing standards.	08/05/2023	99203	1	$350.00	$350.00
2	Second Trimester Routine Prenatal Visit. Monitoring fetal development, blood pressure checks, and nutritional counseling specific to the Houston metropolitan area health guidelines.	09/12/2023	99213	1	$200.00	$200.00
3	Third Trimester Advanced Prenatal Visit. Includes Group B Streptococcus screening coordination, birth plan finalization, and emergency preparedness consultation.	10/02/2023	99214	1	$250.00	$250.00
4	Ultrasound Interpretation and Consultation. Review of anatomy scan results performed at external facility, providing midwifery perspective and patient education.	09/15/2023	76801	1	$150.00	$150.00
5	Postpartum Home Visit (Day 3). Assessment of maternal recovery, newborn vital signs check, breastfeeding support, and lactation consultation within the client's Houston residence.	10/21/2023	99395	1	$275.00	$275.00
6	Postpartum Home Visit (Day 14). Follow-up assessment for maternal mental health screening, infant growth monitoring, and family adjustment counseling.	10/31/2023	99396	1	$225.00	$225.00
7	Administrative Fee for Medical Records Management. Includes documentation of all midwifery care provided, coordination with obstetricians in the Houston area, and filing of necessary state reports.	10/24/2023	99024	1	$100.00	$100.00

Subtotal:	$1,550.00
Texas State Sales Tax (if applicable to specific goods):	$0.00
Insurance Adjustment (Estimated):	-$850.00
Patient Responsibility Total:	$700.00

Terms and Conditions of Service

1. Payment Terms: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge as permitted under Texas law.

2. Insurance Billing: Houston Holistic Midwifery will submit claims to your primary insurance provider. The amount listed as "Patient Responsibility" is an estimate based on your current benefits. You are responsible for any copays, deductibles, or non-covered services as defined by your policy.

3. Scope of Practice: All services rendered by our Certified Professional Midwives (CPMs) and Certified Nurse Midwives (CNMs) adhere to the regulations set forth by the Texas Medical Board and the Texas Board of Nursing. Our midwifery care is designed to support low-risk pregnancies within the United States healthcare framework.

4. Confidentiality: In compliance with HIPAA regulations, all patient information contained in this invoice and associated medical records is strictly confidential.

5. Disputes: Any disputes regarding this invoice must be submitted in writing to our billing department in Houston, Texas, within 15 days of receipt.

6. Method of Payment: We accept checks payable to "Houston Holistic Midwifery," major credit cards, and direct bank transfers. Please include the Invoice Number (INV-2023-10-8842) with all payments.

Authorized Signature (Midwife/Provider):

Elena Rodriguez, CNM

Certified Nurse Midwife

Client Acknowledgement:

__________________________

Date: ________________

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