Invoice Midwife in United States San Francisco –Free Word Template Download with AI
Certified Professional Midwives (CPMs)
1234 Valencia Street, Suite 400
San Francisco, CA 94110, United States
Phone: (415) 555-0199 | Email: [email protected]
CA License No: CPM-88421 | NPI: 1982736455
Bill To:
Client Name: Elena Rodriguez
Address: 567 Irving Street
San Francisco, CA 94122, United States
Phone: (415) 555-0123
Email: [email protected]
Insurance: Out-of-Network / Self-Pay
Service Period & Details:
Service Period: January 15, 2023 – October 10, 2023
Attending Midwife: Sarah Jenkins, CPM
Service Type: Comprehensive Out-of-Hospital Midwifery Care
Location of Birth: Home Birth, San Francisco, CA
| Description of Services | Code / Reference | Quantity | Unit Price | Total |
|---|---|---|---|---|
|
Global Midwifery Care Package Includes all prenatal visits, continuous labor support, delivery attendance, and postpartum care for up to 6 weeks. This comprehensive package reflects the holistic, patient-centered approach standard in San Francisco midwifery practices. |
GLOBAL-01 | 1 | $4,500.00 | $4,500.00 |
|
Prenatal Consultation & Risk Assessment Initial intake, medical history review, and personalized birth plan development tailored to California state regulations and local San Francisco health guidelines. |
PRENATAL-INIT | 1 | $250.00 | $250.00 |
|
Advanced Laboratory Coordination Coordination and interpretation of blood work, urinalysis, and genetic screening panels required for prenatal care in the United States. |
LAB-COORD | 1 | $150.00 | $150.00 |
|
Ultrasound Imaging (Anatomy Scan) Detailed 20-week anatomy scan performed by certified sonographer to monitor fetal development. |
US-ANAT | 1 | $300.00 | $300.00 |
|
Postpartum Home Visits (Extended) Additional home visits beyond the standard package to support breastfeeding, newborn care, and maternal recovery in the client's San Francisco residence. |
POST-EXT | 2 | $175.00 | $350.00 |
|
Newborn Care Package Includes newborn screening coordination, vitamin K administration, and initial health assessment. |
NB-CARE | 1 | $200.00 | $200.00 |
|
Birth Supplies Kit Sterile delivery kit, placenta encapsulation supplies, and emergency equipment used during the birth event. |
SUPPLIES | 1 | $150.00 | $150.00 |
| Subtotal: | $5,900.00 |
| Discount (Early Payment): | -$0.00 |
| Total Due: | $5,900.00 |
Terms, Conditions, and Important Notes:
1. Payment Terms: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge. We accept checks payable to "Golden Gate Midwifery Collective," major credit cards, and HSA/FSA cards.
2. Insurance Reimbursement: As an out-of-network provider in San Francisco, we provide detailed invoices and superbills to assist clients in seeking reimbursement from their insurance carriers. Please retain this document for your records.
3. Scope of Practice: Services rendered are in accordance with the California Midwifery Practice Act and the standards of care for Certified Professional Midwives (CPMs) in the United States.
4. Confidentiality: All client information is protected under HIPAA regulations. This invoice contains protected health information (PHI) and should be handled with appropriate confidentiality.
5. Dispute Resolution: Any disputes regarding this invoice must be submitted in writing within 14 days of receipt. We are committed to resolving any billing concerns amicably and promptly.
6. Thank You: We are honored to have supported your family during this significant life event. Our midwifery team in San Francisco is dedicated to providing safe, compassionate, and empowering care.
Authorized By:
Sarah Jenkins, CPM
Lead Midwife
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