Invoice Psychiatrist in Thailand Bangkok –Free Word Template Download with AI
Specialized Psychiatry & Mental Health Services
123 Sukhumvit Soi 31, Khlong Toei Nuea, Watthana
Bangkok 10110, Thailand
Tel: +66 2 123 4567 | Email: [email protected]
Company Reg. No: 0105562001234
Invoice Number: INV-BKK-2023-0892
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Payment Status: Pending
Bill To (Patient)
Name: Mr. Johnathan Doe
Address: 456 Wireless Road, Lumpini, Pathum Wan
Bangkok 10330, Thailand
ID/Passport No: A12345678
Phone: +66 81 987 6543
Pay From (Insurance / Self-Pay)
Provider: AIA Thailand Insurance Public Company Limited
Policy Number: AIA-TH-99887766
Group ID: CORP-BKK-554
Authorization Code: AUTH-2023-XYZ
| # | Description of Psychiatrist Services | Date of Service | Qty | Unit Price (THB) | Total (THB) |
|---|---|---|---|---|---|
| 1 |
Initial Comprehensive Psychiatric Evaluation ICD-10 Code: Z02.3 Detailed clinical interview conducted by a licensed Psychiatrist in Bangkok to assess mental health status, medical history, and symptomatology. Includes formulation of a preliminary diagnosis and treatment plan. |
Oct 10, 2023 | 1 | 4,500.00 | 4,500.00 |
| 2 |
Psychiatric Follow-Up Consultation (Session 1) ICD-10 Code: F41.1 45-minute session focusing on medication management and monitoring response to treatment. Conducted at our Sukhumvit clinic in Bangkok. |
Oct 17, 2023 | 1 | 2,500.00 | 2,500.00 |
| 3 |
Psychiatric Follow-Up Consultation (Session 2) ICD-10 Code: F41.1 45-minute session focusing on cognitive behavioral strategies and medication adjustment. Conducted at our Sukhumvit clinic in Bangkok. |
Oct 24, 2023 | 1 | 2,500.00 | 2,500.00 |
| 4 |
Psychological Assessment Battery Administered by Clinical Psychologist under Psychiatrist supervision Standardized testing for anxiety and depression levels (HADS, GAD-7, PHQ-9) to support diagnostic accuracy. |
Oct 10, 2023 | 1 | 3,000.00 | 3,000.00 |
| 5 |
Prescription & Medication Dispensing Pharmacy Services Dispensing of prescribed psychotropic medications as per Thai FDA regulations. Includes patient counseling on dosage and side effects. |
Oct 24, 2023 | 1 | 1,200.00 | 1,200.00 |
Important Notes & Terms of Service
1. Payment Instructions: Please remit payment within 30 days of the invoice date. Payments can be made via bank transfer to Bangkok Mind & Wellness Clinic, Kasikorn Bank, Account No: 123-4-56789-0. Please reference Invoice Number INV-BKK-2023-0892.
2. Insurance Claims: This Invoice is issued in accordance with the requirements of major insurance providers operating in Thailand, including AIA, Bupa, and Cigna. If you are paying out-of-pocket, please retain this document for reimbursement claims.
3. Psychiatrist Credentials: All psychiatric services listed on this invoice were performed by board-certified Psychiatrists registered with the Medical Council of Thailand. Our clinic adheres to the highest standards of medical ethics and patient confidentiality as mandated by Thai law.
4. VAT Compliance: This invoice includes the 7% Value Added Tax (VAT) as required by the Revenue Department of Thailand. Our Tax ID is 0105562001234.
5. Confidentiality: Patient information contained within this invoice and associated medical records is strictly confidential. Disclosure is limited to insurance processing and legal requirements.
6. Disputes: Any discrepancies regarding the services rendered or charges applied should be reported to our billing department at [email protected] within 14 days of receipt.
Authorized Signature
Dr. Somchai PrasertLead Psychiatrist & Clinic Director
Bangkok Mind & Wellness Clinic ⬇️ Download as DOCX Edit online as DOCX
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