Invoice Radiologist in Brazil Brasília –Free Word Template Download with AI
Specialized Radiology Center
Address: SHIS QI 15, Conjunto 2, Lago Sul
Brasília, DF - 71625-000, Brazil
CNPJ: 12.345.678/0001-90
Phone: +55 (61) 3333-4444
Email: [email protected]
Invoice Number: #BR-2023-8942
Date of Issue: October 24, 2023
Due Date: November 07, 2023
Service Period: October 2023
Bill To:
Dr. Ricardo Mendes - Private Practice
Address: SIA Trecho 2, Lote 500, Asa Sul
Brasília, DF - 71200-030, Brazil
CPF: 123.456.789-00
Reference: Referral Agreement #RM-2023
This document serves as a formal invoice for professional radiological services rendered by a certified Radiologist operating within the jurisdiction of Brasília, the Federal District of Brazil. The services detailed below were performed in accordance with the technical standards established by the Brazilian Society of Radiology and Diagnostic Imaging (SBRIM) and comply with the regulatory requirements of the Federal Council of Medicine (CFM). As a premier diagnostic facility in the capital of Brazil, Capital Imaging & Diagnostics ensures that all imaging procedures, from acquisition to interpretation, meet the highest levels of clinical excellence required for patient care in Brasília.
| Description of Services | Procedure Code (CBHPM) | Quantity | Unit Price (BRL) | Total (BRL) |
|---|---|---|---|---|
|
Magnetic Resonance Imaging (MRI) - Brain with Contrast Comprehensive analysis by Senior Radiologist including detailed report on neurological structures. |
30204.03-0 | 1 | R$ 1,200.00 | R$ 1,200.00 |
|
Computed Tomography (CT) - Chest with Contrast High-resolution imaging for pulmonary assessment, interpreted by specialist Radiologist. |
30104.03-0 | 1 | R$ 950.00 | R$ 950.00 |
|
Mammography - Bilateral with Tomosynthesis Advanced breast imaging screening and diagnostic evaluation. |
30204.01-0 | 1 | R$ 600.00 | R$ 600.00 |
|
Ultrasound - Abdominal Complete Evaluation of liver, gallbladder, pancreas, spleen, and kidneys. |
30104.01-0 | 2 | R$ 350.00 | R$ 700.00 |
|
Professional Fee - Radiologist Interpretation Specialized medical interpretation and reporting for complex cases. |
40104.01-0 | 5 | R$ 150.00 | R$ 750.00 |
|
Emergency After-Hours Consultation Urgent radiological assessment provided outside standard hours in Brasília. |
40104.05-0 | 1 | R$ 400.00 | R$ 400.00 |
| Subtotal: | R$ 4,600.00 |
| ICMS (Tax - 18%): | R$ 828.00 |
| ISS (Service Tax - 5%): | R$ 230.00 |
| TOTAL DUE: | R$ 5,658.00 |
Payment Instructions & Terms:
Payment is to be made via bank transfer to the following account located in Brasília, Brazil:
Bank: Banco do Brasil
Agency: 1234-5
Account: 98765-4
Account Holder: Capital Imaging & Diagnostics Ltda.
PIX Key: [email protected]
Please reference Invoice #BR-2023-8942 in the payment description. Late payments may incur interest charges as per Brazilian commercial law. This invoice is valid for tax deduction purposes in Brazil.
Legal Disclaimer and Professional Standards:
This invoice represents the financial transaction for medical imaging services provided by a licensed Radiologist in Brasília, Federal District, Brazil. All procedures were conducted under the supervision of qualified medical professionals registered with the Regional Council of Medicine of the Federal District (CRM-DF). The images and reports generated are the intellectual property of Capital Imaging & Diagnostics and are intended solely for the medical use of the referring physician and the patient. The use of advanced technology, including MRI and CT scanners, adheres to the safety protocols mandated by the National Nuclear Energy Commission (CNEN) of Brazil. By accepting this invoice, the client acknowledges receipt of the radiological reports and agrees to the terms of service outlined in the referral agreement. This document is issued in compliance with the Brazilian National Health Surveillance Agency (ANVISA) regulations regarding medical billing and documentation.
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