Invoice Psychiatrist in South Africa Johannesburg –Free Word Template Download with AI
Private Psychiatry Practice
123 Sandton Drive, Sandton City
Johannesburg, Gauteng, 2196
South Africa
Phone: +27 11 555 0123
Email: [email protected]
Practitioner Number: HPCSA 0000000000
Bill To (Patient)Mr. Johnathan Doe
45 Rivonia Road
Rivonia, Johannesburg
Gauteng, 2128
South Africa
Medical Aid: Discovery Health
Member Number: 123456789
Dependent Number: 01
Service ProviderDr. Sarah Mokoena
Specialist Psychiatrist
Registered with the Health Professions Council of South Africa (HPCSA)
Panel Provider for Discovery Health, Bonitas, and Momentum
Description of Services Rendered| Date | Description of Service | Medical Aid Code | Fee (ZAR) | Paid by Aid (ZAR) | Balance (ZAR) |
|---|---|---|---|---|---|
| 01 Oct 2023 | Initial Psychiatric Consultation (60 mins). Comprehensive assessment including history taking, mental state examination, and formulation of diagnosis. | 1001 | R 2,500.00 | R 1,800.00 | R 700.00 |
| 08 Oct 2023 | Follow-up Psychiatric Consultation (30 mins). Review of medication efficacy, side effect monitoring, and adjustment of treatment plan. | 1002 | R 1,500.00 | R 1,200.00 | R 300.00 |
| 15 Oct 2023 | Psychiatric Consultation (30 mins). Focus on cognitive behavioral strategies and ongoing pharmacological management. | 1002 | R 1,500.00 | R 1,200.00 | R 300.00 |
| 20 Oct 2023 | Psychiatric Report for Employer/Insurance. Detailed clinical report outlining diagnosis, prognosis, and fitness for work assessment. | 1050 | R 3,500.00 | R 0.00 | R 3,500.00 |
Please settle the outstanding balance by the due date indicated above. Payments can be made via Electronic Funds Transfer (EFT) to the following bank account:
- Bank: First National Bank (FNB)
- Branch: Sandton (Code: 250655)
- Account Name: Dr. Sarah Mokoena Psychiatry
- Account Number: 62012345678
- Account Type: Cheque Account
- Reference: INV-2023-10-045
Note: Please ensure you use the invoice number as your payment reference to facilitate quick allocation of funds.
Terms and Conditions- Currency: All amounts are quoted in South African Rand (ZAR).
- Medical Aid Claims: Claims are submitted directly to the relevant medical aid scheme. The patient is responsible for any co-payments or shortfalls not covered by their specific medical aid plan.
- VAT: VAT is charged only on services that are not covered by medical aid (e.g., specific reports), in accordance with South African tax laws. Consultations covered by medical aid are VAT-exempt.
- Payment Terms: Payment is due within 30 days of the invoice date. Late payments may incur a monthly interest charge of 2%.
- Disputes: Any discrepancies regarding this invoice must be reported within 14 days of receipt.
- Confidentiality: All patient information is handled in strict confidence in accordance with the Protection of Personal Information Act (POPIA) of South Africa.
Thank you for choosing our psychiatric services in Johannesburg.
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