Invoice Midwife in United States Miami –Free Word Template Download with AI
1200 Brickell Avenue, Suite 400
Miami, FL 33131
United States
Phone: (305) 555-0199
Email: [email protected]
License No: FL-MW-88291
Invoice Number: INV-2023-10-884
Date Issued: October 24, 2023
Due Date: November 24, 2023
Payment Method: Check, Credit Card, or HSA/FSA
Bill To:
Client Name: Elena Rodriguez
Address: 4500 SW 8th Street
Miami, FL 33134
United States
Phone: (786) 555-0123
Insurance: Blue Cross Blue Shield of Florida
Policy ID: BCBS-FL-99887766
Service Period & Details:
Service Period: January 15, 2023 – October 10, 2023
Provider: Sarah Jenkins, CNM (Certified Nurse Midwife)
Service Type: Comprehensive Prenatal, Labor, Delivery, and Postpartum Care
Location: Miami Coastal Birth Center, Miami, FL
| # | Description of Midwifery Services | Date | CPT Code | Amount (USD) |
|---|---|---|---|---|
| 1 | Initial Prenatal Consultation & Care Plan: Comprehensive health assessment, medical history review, and establishment of a personalized birth plan tailored to the client's needs in Miami. | Jan 15, 2023 | 99203 | $250.00 |
| 2 | Monthly Prenatal Visits (Months 1-6): Includes fetal heart monitoring, blood pressure checks, nutritional counseling, and education on pregnancy milestones. | Feb-Jun 2023 | 59425 | $1,200.00 |
| 3 | Bi-Weekly Prenatal Visits (Months 7-8): Increased monitoring frequency, preparation for labor, and discussion of pain management options. | Jul-Aug 2023 | 59425 | $800.00 |
| 4 | Weekly Prenatal Visits (Month 9): Final preparations, cervical checks, and confirmation of birth logistics. | Sep 2023 | 59425 | $600.00 |
| 5 | Labor and Delivery Attendance: Continuous support, monitoring, and clinical management during labor and vaginal delivery at the Miami Coastal Birth Center. | Oct 10, 2023 | 59400 | $3,500.00 |
| 6 | Postpartum Care Package: Includes 4 postpartum visits for mother and newborn, breastfeeding support, and emotional well-being check-ins. | Oct-Nov 2023 | 59425 | $750.00 |
| 7 | Newborn Care Services: Initial newborn assessment, vital signs monitoring, and guidance on infant care practices. | Oct 10, 2023 | 99460 | $300.00 |
| 8 | Administrative & Documentation Fees: Processing of birth certificates, medical records, and insurance coordination specific to Florida regulations. | Oct 2023 | 99024 | $150.00 |
Important Notes & Payment Instructions:
Thank you for choosing Miami Coastal Midwifery for your maternity care journey. We are dedicated to providing compassionate, evidence-based midwifery care in the heart of Miami, Florida.
Payment Terms: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge. Please make checks payable to "Miami Coastal Midwifery" and include your invoice number in the memo line.
Insurance: This invoice reflects the amount remaining after insurance processing. If you have questions about your coverage, please contact our billing department or your insurance provider directly.
Disputes: If you have any questions or disputes regarding this invoice, please contact us within 15 days of receipt. We are committed to resolving any issues promptly and professionally.
Confidentiality: All patient information is kept strictly confidential in accordance with HIPAA regulations and Florida state laws.
Authorized Signature:
Sarah Jenkins, CNM
Lead Midwife, Miami Coastal Midwifery
Client Acknowledgment:
Elena Rodriguez
Date: _______________
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