Invoice Radiologist in Bangladesh Dhaka –Free Word Template Download with AI
House #45, Road #12, Dhanmondi R/A
Dhaka-1205, Bangladesh
Phone: +880 2 9123456 | Email: [email protected]
TIN: 123456789012 | BIN: 123456789012
Invoice Number: INV-2023-10-089
Date: October 24, 2023
Due Date: November 07, 2023
Payment Terms: Net 14 Days
Bill To:
Apex Medical Insurance Ltd.
Claims Department
Level 15, Bashundhara City Tower A
Plot #12, Block #A, Bashundhara R/A
Dhaka-1229, Bangladesh
Reference ID: APX-CLAIM-998877
Patient Details:
Name: Md. Rafiqul Islam
Policy Number: APX-POL-554433
Date of Service: October 23, 2023
| # | Description of Radiological Services | Quantity | Unit Price (BDT) | Total (BDT) |
|---|---|---|---|---|
| 1 |
MRI Brain with Contrast Performed by Dr. Salma Akter, Consultant Radiologist. Includes intravenous contrast administration and detailed image analysis. |
1 | 12,500.00 | 12,500.00 |
| 2 |
CT Scan Chest (High Resolution) Performed by Dr. Kamal Hossain, Senior Radiologist. Includes 3D reconstruction and pulmonary embolism protocol. |
1 | 8,000.00 | 8,000.00 |
| 3 |
Radiologist Professional Fee (Interpretation) Comprehensive diagnostic report for MRI Brain and CT Chest by Board-Certified Radiologist. |
2 | 2,500.00 | 5,000.00 |
| 4 |
Digital Imaging Storage & CD DICOM format images on CD for patient records and second opinion. |
2 | 500.00 | 1,000.00 |
| 5 |
Emergency Consultation Fee Urgent radiological assessment outside standard hours. |
1 | 3,000.00 | 3,000.00 |
Amount in words: Thirty Thousand Nine Hundred Seventy-Five Taka Only.
Payment Instructions
Please make payment via bank transfer to the following account:
Bank Name: BRAC Bank PLC
Branch: Dhanmondi Branch, Dhaka
Account Name: Dhaka Advanced Radiology Center Ltd.
Account Number: 1234567890123456
Routing/SWIFT Code: BRACBDDH
Note: Please include the Invoice Number (INV-2023-10-089) in the payment reference.
Terms and Conditions
- This invoice is issued by Dhaka Advanced Radiology Center, a licensed medical imaging facility operating in Dhaka, Bangladesh, in accordance with the Bangladesh Medical and Dental Council (BMDC) regulations.
- All radiological services listed above were performed by qualified and registered radiologists specializing in diagnostic imaging.
- Payment is due within 14 days of the invoice date. Late payments may incur a penalty of 1.5% per month on the outstanding balance.
- Any discrepancies in the billing must be reported within 7 days of receiving this invoice. After this period, the invoice will be considered accepted.
- This invoice is valid for insurance claims submission in Bangladesh. Please retain a copy for your records.
- All images and reports are the property of Dhaka Advanced Radiology Center until full payment is received.
- In case of any disputes, the courts of Dhaka, Bangladesh shall have exclusive jurisdiction.
Authorized Signature
Dr. Salma Akter
Chief Radiologist & Director
Dhaka Advanced Radiology Center
Received By
_________________________
Name & Designation
Date
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT