Invoice Psychiatrist in Russia Saint Petersburg –Free Word Template Download with AI
Legal Entity: LLC "NeuroPsychiatric Center SPb"
Address: Nevsky Prospect, 120, Office 45, Saint Petersburg, Russia, 191025
Phone: +7 (812) 555-0199
Email: [email protected]
INN: 7801234567 | KPP: 780101001
License No: LO-78-01-001234 (Issued by Ministry of Health of the Russian Federation)
Invoice Number: INV-RU-SPB-2023-0892
Date of Issue: October 24, 2023
Due Date: November 07, 2023
Currency: Russian Ruble (RUB)
Bill To (Patient / Insurance Provider)
Name: Ivan Petrovich Sokolov
Address: Fontanka Embankment, 42, Apt 12, Saint Petersburg, Russia, 191186
Passport Series/Number: 45** ****
Policy Number (if applicable): OMS-78-2023-998877
Phone: +7 (921) 555-1234
Service Location
Clinic Branch: Central District, Saint Petersburg
Attending Psychiatrist: Dr. Elena Mikhailovna Volkova, MD, PhD
Specialization: Clinical Psychiatry, Psychotherapy, Neuropsychiatry
Medical License: L001-00123-78/00123456
| # | Description of Psychiatric Services | Quantity / Hours | Unit Price (RUB) | Total Amount (RUB) |
|---|---|---|---|---|
| 1 |
Initial Comprehensive Psychiatric Evaluation Detailed clinical interview, mental status examination, and review of medical history conducted by Dr. Volkova. Includes diagnostic assessment according to ICD-10 and DSM-5 criteria. |
1 | 8,500.00 | 8,500.00 |
| 2 |
Individual Psychotherapy Session (CBT) Cognitive Behavioral Therapy session focused on anxiety management and mood regulation. Duration: 60 minutes. |
4 | 6,000.00 | 24,000.00 |
| 3 |
Psychopharmacological Consultation & Prescription Medication review, dosage adjustment, and prescription issuance for antidepressants and anxiolytics. Includes monitoring of potential side effects. |
2 | 4,500.00 | 9,000.00 |
| 4 |
Neuropsychological Testing Battery Assessment of cognitive functions including memory, attention, and executive function. Includes interpretation report. |
1 | 12,000.00 | 12,000.00 |
| 5 |
Family Therapy Session Joint session with patient and family members to discuss treatment plan and support strategies. Duration: 90 minutes. |
1 | 7,500.00 | 7,500.00 |
| 6 |
Medical Documentation & Certification Preparation of official medical certificates, sick leave notes (bolnichny list), and referral letters for social services in Saint Petersburg. |
1 | 2,500.00 | 2,500.00 |
Payment Terms and Conditions
This invoice is issued in accordance with the Federal Law of the Russian Federation "On the Protection of Consumer Rights" and the regulations governing medical services in Saint Petersburg. Payment is due within 14 days from the date of issue. Late payments may incur a penalty of 0.1% per day.
Bank Details for Transfer:
Beneficiary: LLC "NeuroPsychiatric Center SPb"
Bank Name: Sberbank of Russia, Saint Petersburg Branch
BIC: 044525225
Account Number: 40702810938000012345
Correspondent Account: 30101810500000000225
Purpose of Payment: Payment for psychiatric services, Invoice INV-RU-SPB-2023-0892
Important Notice: All psychiatric services provided are confidential and protected under Russian medical secrecy laws. This invoice contains personal data and should be handled securely.
Authorized Signature:
Dr. Elena M. Volkova
Chief Psychiatrist
NeuroPsychiatric Center SPb
Received By:
Ivan P. Sokolov
Date: _______________
Signature: _______________
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT