Invoice Paramedic in United States Houston –Free Word Template Download with AI
1200 Main Street, Suite 400
Houston, Texas 77002
United States
Phone: (713) 555-0199 | Fax: (713) 555-0198
Email: [email protected]
TIN: 74-1234567
Invoice #: HM-2023-8942
Date: October 24, 2023
Due Date: November 24, 2023
Reference: Incident #4492-HOU
Bill ToMr. James Anderson
4500 Westheimer Road, Apt 3B
Houston, Texas 77027
United States
Insurance Provider: Blue Cross Blue Shield of Texas
Policy Number: TX-99887766
Group Number: 445566
Paramedic Services RenderedThe following invoice details the emergency medical transport and advanced life support services provided by certified Paramedics in Houston, Texas. These services were rendered in accordance with the Texas Administrative Code and local Houston municipal health regulations. The patient was transported from the scene of the incident to Memorial Hermann Hospital.
| Description of Service | Quantity | Unit Price | Total |
|---|---|---|---|
|
Emergency Ambulance Transport (ALS) Advanced Life Support transport within Houston city limits. Includes mileage from dispatch location to receiving facility. |
1 | $1,250.00 | $1,250.00 |
|
Paramedic On-Scene Assessment Initial patient evaluation, vital signs monitoring, and triage performed by licensed Paramedic. |
1 | $350.00 | $350.00 |
|
Advanced Cardiac Life Support (ACLS) Implementation of ACLS protocols, including 12-lead ECG analysis and interpretation. |
1 | $450.00 | $450.00 |
|
Intravenous (IV) Therapy Setup Establishment of peripheral IV access and administration of fluids as prescribed. |
1 | $175.00 | $175.00 |
|
Medication Administration Administration of emergency pharmaceuticals including analgesics and anti-emetics. |
3 | $45.00 | $135.00 |
|
Oxygen Therapy Continuous oxygen delivery via non-rebreather mask during transport. |
1 | $85.00 | $85.00 |
|
Medical Record Documentation Preparation of Patient Care Report (PCR) compliant with Houston Fire Department standards. |
1 | $50.00 | $50.00 |
Please remit payment within 30 days of the invoice date. Late payments may be subject to a 1.5% monthly finance charge in accordance with Texas state law.
- Check: Make checks payable to "Houston Metro Emergency Medical Services" and mail to the address listed in the header.
- Online: Visit www.houstonmetroems.com/pay-bill and enter Invoice #HM-2023-8942.
- Phone: Call our billing department at (713) 555-0199 to pay by credit card.
Important Notice Regarding Paramedic Services:
This invoice represents the standard charges for emergency medical services provided in Houston, Texas. The services were performed by NREMT-certified Paramedics operating under the medical direction of the Houston Metro Medical Director. While every effort is made to ensure accuracy, this invoice is an estimate of charges. Please review the itemized list carefully. If you have questions regarding specific medical procedures or charges, please contact our patient advocacy team.
Insurance Information: We have submitted a claim to your insurance provider listed above. The "Insurance Adjustment" reflects the amount covered by your plan. You are responsible for any remaining balance, including deductibles and co-pays. If you believe this invoice contains an error, please notify us in writing within 60 days.
Privacy Policy: In compliance with HIPAA regulations, your medical information is kept strictly confidential. This invoice contains limited medical information necessary for billing purposes.
Authorized Signature
Sarah Jenkins, RN, Billing Manager
Houston Metro EMS
Patient/Guarantor Signature
Date Received:
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