Invoice Psychiatrist in Brazil Brasília –Free Word Template Download with AI
CRM-DF: 12.345 | CRMP: 6789
Quadra 702, Bloco A, Sala 305, Asa Norte
Brasília, DF - Brazil, CEP: 70700-000
Email: [email protected]
Phone: +55 (61) 3333-4444
Invoice #: INV-2023-10-042
Date: October 24, 2023
Due Date: November 07, 2023
Bill To:
Patient Name: Maria Clara Souza
CPF: ***.***.***-00
Address: SHIS QI 15, Casa 22, Lago Sul
City: Brasília, DF - Brazil
Insurance Provider: Unimed Brasília (Policy #99887766)
| Description of Services | CBHPM Code | Date | Qty | Unit Price (BRL) | Total (BRL) |
|---|---|---|---|---|---|
|
Initial Psychiatric Consultation Comprehensive clinical interview, diagnostic assessment, and formulation of treatment plan. Includes review of medical history and current psychiatric symptoms. |
30101.04-0 | Oct 10, 2023 | 1 | R$ 450.00 | R$ 450.00 |
|
Follow-up Psychiatric Consultation Monitoring of medication efficacy, side effect management, and adjustment of therapeutic strategy. |
30101.05-8 | Oct 17, 2023 | 1 | R$ 350.00 | R$ 350.00 |
|
Psychiatric Follow-up Consultation Continued monitoring of patient progress in Brasília clinic. |
30101.05-8 | Oct 24, 2023 | 1 | R$ 350.00 | R$ 350.00 |
|
Psychological Assessment Report Detailed written report for insurance or legal purposes regarding psychiatric status. |
30102.02-3 | Oct 24, 2023 | 1 | R$ 200.00 | R$ 200.00 |
| Subtotal: | R$ 1,350.00 |
| Discount: | R$ 0.00 |
| TOTAL DUE: | R$ 1,350.00 |
Payment Instructions:
Payment is due within 15 days of the invoice date. Please make payments via bank transfer to the following account located in Brasília:
- Bank: Banco do Brasil
- Agency: 1234-5
- Account: 98765-4
- Account Holder: Ricardo Mendes
- PIX Key: [email protected]
Important Notes for Patients in Brazil:
This invoice serves as official documentation for reimbursement claims with private health insurance companies (Plano de Saúde) operating in Brazil. Please ensure you submit this document along with the medical prescription and any required forms to your provider.
As a licensed Psychiatrist practicing in the Federal District, all services rendered comply with the regulations set by the Federal Council of Medicine (CFM) and the Regional Council of Medicine of the Federal District (CRM-DF).
For tax purposes, this invoice is issued under the Simples Nacional regime. If you require a detailed fiscal receipt (Nota Fiscal de Serviços) for corporate reimbursement, please contact the office within 30 days.
Thank you for trusting our psychiatric care services in Brasília. We are committed to providing high-quality mental health support tailored to your needs.
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