Invoice Radiologist in Saudi Arabia Jeddah –Free Word Template Download with AI
Professional Medical Imaging Services
Al Rawdah District, King Fahd Road
Jeddah, Makkah Province, Saudi Arabia
Phone: +966 12 555 7890
Email: [email protected]
VAT Registration Number: 300123456789003
Commercial Registration: 1010023456
Invoice Number: INV-2024-00892
Date of Issue: January 15, 2024
Due Date: February 14, 2024
Payment Terms: Net 30 Days
Billed To:
Jeddah Medical Insurance Company
Healthcare Insurance Division
King Abdullah Financial District
Jeddah, Saudi Arabia
Attn: Claims Processing Department
Reference Number: REF-JED-2024-5678
Value Added Tax (VAT) Notice: This invoice is issued in accordance with the Saudi Arabian General Authority of Zakat and Tax (GAZT) regulations. A VAT rate of 15% is applied to all taxable services as per the current tax law in the Kingdom of Saudi Arabia.| # | Description of Radiological Services | Quantity | Unit Price (SAR) | Total (SAR) | ICD-10 Code |
|---|---|---|---|---|---|
| 1 |
Computed Tomography (CT) Scan - Abdomen & Pelvis with Contrast Performed by Dr. Ahmed Al-Rashid, Board-Certified Radiologist Patient: Mohammed Al-Fahad Date of Service: January 10, 2024 Detailed diagnostic imaging including pre-procedure consultation and post-procedure radiological report |
1 | 1,200.00 | 1,200.00 | R10.9 |
| 2 |
Magnetic Resonance Imaging (MRI) - Brain without Contrast Performed by Dr. Sarah Al-Otaibi, Senior Radiologist Patient: Fatima Al-Zahrani Date of Service: January 11, 2024 High-resolution neuroimaging with comprehensive radiological interpretation |
1 | 1,800.00 | 1,800.00 | G43.9 |
| 3 |
Ultrasound Examination - Abdominal Complete Performed by Dr. Khalid Al-Mutairi, Radiologist Patient: Abdullah Al-Saud Date of Service: January 12, 2024 Real-time imaging of liver, gallbladder, pancreas, spleen, kidneys, and major blood vessels |
1 | 650.00 | 650.00 | K80.9 |
| 4 |
Digital X-Ray - Chest PA & Lateral Views Performed by Dr. Noura Al-Harbi, Radiologist Patient: Layla Al-Qahtani Date of Service: January 13, 2024 Standard radiographic examination with immediate preliminary reading |
2 | 250.00 | 500.00 | J18.9 |
| 5 |
Mammography Screening - Bilateral Digital Performed by Dr. Huda Al-Ghamdi, Breast Imaging Specialist Patient: Reem Al-Dosari Date of Service: January 14, 2024 Comprehensive breast imaging with BI-RADS assessment and detailed radiological report |
1 | 900.00 | 900.00 | Z12.4 |
| 6 |
Interventional Radiology Procedure - Image-Guided Biopsy Performed by Dr. Faisal Al-Mansour, Interventional Radiologist Patient: Omar Al-Harbi Date of Service: January 14, 2024 Ultrasound-guided core needle biopsy with specimen handling and pathology coordination |
1 | 2,500.00 | 2,500.00 | C78.9 |
| Subtotal: | 7,550.00 SAR |
| VAT (15%): | 1,132.50 SAR |
| Total Amount Due: | 8,682.50 SAR |
Payment Instructions and Important Notes:
Bank Transfer Details:
Bank Name: Al Rajhi Bank, Jeddah Branch
Account Name: Advanced Radiology Center Jeddah
IBAN: SA03 8000 0000 6080 1016 7519
SWIFT Code: NBSASARXXXX
Payment Reference: Please include Invoice Number INV-2024-00892 in your payment reference.
Service Quality Assurance: All radiological examinations listed on this invoice have been performed by qualified, licensed radiologists practicing in accordance with the standards set by the Saudi Commission for Health Specialties (SCFHS) and the Ministry of Health of Saudi Arabia. Each procedure includes a comprehensive written report delivered within 24-48 hours of the examination.
Insurance Claims: This invoice is formatted to comply with the requirements of the Council of Cooperative Health Insurance (CCHI) in Saudi Arabia. All ICD-10 codes have been assigned by the attending radiologist based on clinical findings. Supporting documentation, including DICOM images and detailed radiological reports, are available upon request for claims verification purposes.
Dispute Resolution: In the event of any discrepancies or questions regarding this invoice, please contact our billing department within 15 days of the invoice date. Our team is committed to resolving any issues promptly and professionally in accordance with Saudi Arabian commercial law.
Confidentiality: All patient information and medical data associated with these services are handled in strict compliance with the Saudi Arabian Personal Data Protection Law and international medical confidentiality standards.
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