Invoice Midwife in United States New York City –Free Word Template Download with AI

Bill To: Jane Doe
456 Park Avenue South
Apt 12B
New York, NY 10016
United States New York City Patient Name: Jane Doe Date of Birth: 05/12/1990 Invoice Number: INV-2023-10-045 Date of Issue: October 24, 2023 Due Date: November 24, 2023 Service Period: January 2023 - October 2023

Dear Ms. Doe,

This document serves as an official Invoice for the comprehensive midwifery care services provided by Manhattan Holistic Midwifery. As a licensed Midwife operating within the jurisdiction of United States New York City, we are committed to providing safe, evidence-based, and compassionate care throughout your pregnancy, labor, birth, and postpartum journey.

The charges detailed below reflect the professional fees for prenatal visits, labor attendance, delivery assistance, and postpartum follow-up care rendered in accordance with the standards set by the New York State Department of Health and the Midwives Alliance of North America. Please review the line items carefully. If you have insurance coverage, this Invoice may be submitted for reimbursement. If paying out-of-pocket, please adhere to the payment terms outlined at the bottom of this document.

#	Description of Midwifery Services	Date Rendered	CPT Code	Amount (USD)
1	Initial Prenatal Consultation & History Comprehensive intake assessment, medical history review, and establishment of care plan by licensed Midwife. Includes initial physical examination and laboratory ordering.	01/15/2023	99203	$350.00
2	Prenatal Visits (First & Second Trimester) Series of 8 routine prenatal check-ups conducted in our New York City clinic. Includes fundal height measurement, fetal heart rate monitoring, blood pressure checks, and nutritional counseling.	02/01 - 06/15/2023	99213	$1,200.00
3	Prenatal Visits (Third Trimester) Series of 6 intensive prenatal check-ups. Includes Group B Strep screening, birth plan finalization, and preparation for labor. Services provided by primary Midwife and associate.	07/01 - 09/20/2023	99214	$900.00
4	Labor, Delivery, and Immediate Postpartum Care Continuous one-on-one support during labor and delivery at home/birth center. Includes management of the second stage of labor, delivery of the infant and placenta, and initial newborn assessment (APGAR).	10/05/2023	59400	$3,500.00
5	Postpartum Care Package Includes 3 home visits within the first two weeks postpartum. Assessment of maternal recovery, breastfeeding support, and newborn health checks. Essential follow-up care provided by your Midwife.	10/07 - 10/20/2023	99395	$600.00
6	Newborn Care & Registration Assistance Assistance with birth certificate registration in New York City and initial newborn care education.	10/10/2023	99211	$150.00
7	Emergency On-Call Fee Fee covering 24/7 availability of the Midwife team during the final weeks of pregnancy and immediate postpartum period.	09/01 - 10/20/2023	99291	$400.00

Subtotal:	$7,100.00
Discount (Early Payment):	-$0.00
NY State Sales Tax (Exempt - Medical):	$0.00
Total Due:	$7,100.00

Payment Terms & Important Information

Payment Methods: We accept bank transfers (ACH), checks payable to "Manhattan Holistic Midwifery," and major credit cards (a 3% processing fee applies to credit card transactions).
Due Date: Payment is due within 30 days of the date of this Invoice. Late payments may incur a 1.5% monthly interest charge.
Insurance: If you have private insurance or Medicaid coverage in United States New York City, please submit this Invoice along with the attached Superbill to your provider. We are not a direct-billing provider for all plans.
Midwifery Scope: All services listed were performed by licensed Certified Professional Midwives (CPMs) or Certified Nurse Midwives (CNMs) authorized to practice in New York State.
Questions: For any discrepancies regarding this Invoice, please contact our billing department at (212) 555-0199 within 10 business days.

Authorized By: Sarah Johnson, CPM
Lead Midwife Client Acknowledgement: Signature / Date ⬇️ Download as DOCX Edit online as DOCX

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