Invoice Radiologist in Philippines Manila –Free Word Template Download with AI
123 Medical Avenue, Ortigas Center
Pasig City, Metro Manila, Philippines 1605
Tel: +63 (2) 8555-0199 | Email: [email protected]
TIN: 000-123-456-000 | BIR Reg. No: 123-456-789-000-000
Invoice Number: INV-2023-10-089
Date Issued: October 24, 2023
Due Date: November 24, 2023
Payment Terms: Net 30 Days
Bill To:
St. Luke's Medical Group Insurance
Claims Department
8050 EDSA, Brgy. Ugong, Mandaluyong City
Metro Manila, Philippines 1550
Patient Name: Maria Clara Santos
Patient ID: MCR-8892-10
Referring Physician: Dr. Jose Rizal, MD
| # | Description of Radiological Services | Date of Service | Quantity | Unit Price (PHP) | Total (PHP) |
|---|---|---|---|---|---|
| 1 |
Computed Tomography (CT) Scan - Abdomen & Pelvis with Contrast Performed by: Dr. Elena Cruz, MD, FRCR (Board Certified Radiologist) Includes intravenous contrast administration and detailed diagnostic report. |
Oct 20, 2023 | 1 | 15,500.00 | 15,500.00 |
| 2 |
Magnetic Resonance Imaging (MRI) - Lumbar Spine Performed by: Dr. Elena Cruz, MD, FRCR High-resolution imaging without contrast. Includes interpretation by senior radiologist. |
Oct 21, 2023 | 1 | 22,000.00 | 22,000.00 |
| 3 |
Ultrasound - Abdominal (Complete) Performed by: Dr. Mark Reyes, MD (Radiologist) Real-time imaging of liver, gallbladder, pancreas, spleen, and kidneys. |
Oct 22, 2023 | 1 | 4,500.00 | 4,500.00 |
| 4 |
Digital Radiography (X-Ray) - Chest PA & Lateral Performed by: Dr. Mark Reyes, MD Standard diagnostic imaging for respiratory assessment. |
Oct 22, 2023 | 1 | 1,200.00 | 1,200.00 |
| 5 |
Specialist Radiologist Consultation & Report Review Comprehensive review of all imaging studies by a senior radiologist in Manila. |
Oct 23, 2023 | 1 | 3,000.00 | 3,000.00 |
Important Notes & Payment Instructions:
This invoice represents the professional fees and facility charges for radiological services rendered at Manila Advanced Radiology Center. All services were performed by licensed Radiologists accredited by the Philippine Board of Radiology.
Payment Methods:
Please remit payment via bank transfer to:
Bank: BDO Unibank
Account Name: Manila Advanced Radiology Center Inc.
Account Number: 1234-5678-9012
Branch: Ortigas Center Branch, Metro Manila
For payments made via check, please make checks payable to "Manila Advanced Radiology Center Inc." and mail to the address listed in the header.
Terms:
Payment is due within 30 days from the date of this invoice. Late payments may incur a penalty fee of 1.5% per month on the outstanding balance. Please include the Invoice Number (INV-2023-10-089) as a reference in all payments.
Compliance:
This invoice is issued in accordance with the regulations of the Bureau of Internal Revenue (BIR) of the Philippines. All prices are quoted in Philippine Pesos (PHP).
Authorized by:
Dr. Elena Cruz, MD, FRCR
Chief Radiologist
Manila Advanced Radiology Center
Received by:
__________________________
Name & Signature
Date
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