Invoice Radiologist in United States Chicago –Free Word Template Download with AI

Bill To (Patient)

Mr. James Anderson

742 Evergreen Terrace

Chicago, IL 60614, United States

Patient ID: PAT-998877

Date of Birth: 05/12/1978

Insurance / Payer

Blue Cross Blue Shield of Illinois

Policy Number: BCBS-IL-445566

Group Number: GRP-CH-001

Referring Physician: Dr. Sarah Jenkins, MD

Referring Facility: Northwestern Memorial Hospital

Date	Description of Radiology Services	CPT Code	Quantity	Amount (USD)
Oct 02, 2023	Magnetic Resonance Imaging (MRI) - Brain Professional Component: Interpretation by Board-Certified Radiologist. Detailed analysis of cranial structures without contrast. Includes review of clinical history and correlation with prior imaging studies available in the Chicago medical network.	70553	1	$450.00
Oct 05, 2023	Computed Tomography (CT) - Chest with Contrast Technical & Professional Components. High-resolution CT scan of the thorax. Performed at our downtown Chicago facility. Includes intravenous contrast administration and comprehensive radiological report detailing pulmonary and mediastinal findings.	71260	1	$875.00
Oct 10, 2023	Ultrasound - Abdomen, Complete Professional Component Only. Real-time sonographic evaluation of the liver, gallbladder, pancreas, spleen, kidneys, and aorta. Interpretation provided by senior radiologist specializing in abdominal imaging.	76700	1	$320.00
Oct 15, 2023	Mammography - Diagnostic, Bilateral Technical & Professional Components. Diagnostic mammographic screening including additional spot compression views as clinically indicated. Performed in compliance with the Mammography Quality Standards Act (MQSA).	77065	1	$550.00
Oct 18, 2023	Consultation - Complex Case Review Professional Component. Second opinion consultation regarding multi-modal imaging findings. Includes tele-radiology conference with referring physician in Chicago to discuss treatment planning and differential diagnosis.	99245	1	$600.00

Subtotal: $2,795.00 Insurance Adjustment (-): -$1,200.00 Insurance Payment Applied (+): +$1,200.00 Patient Responsibility (Co-pay/Deductible): $595.00 TOTAL DUE: $595.00

Payment Instructions & Important Information

Payment Methods: This invoice may be paid via credit card (Visa, MasterCard, Amex), check, or electronic bank transfer. Please make checks payable to "Windy City Advanced Radiology."

Online Payment: For your convenience, you may pay this invoice securely online at www.windycityrad.com/pay using Invoice Number INV-CHI-2023-8842.

Insurance Claims: We have submitted the primary claim to Blue Cross Blue Shield of Illinois. The amount due represents the patient's estimated responsibility based on current benefit information. If you believe this amount is incorrect, please contact our billing department with your Explanation of Benefits (EOB).

Financial Assistance: As a healthcare provider operating in Chicago, United States, we are committed to accessibility. If you are experiencing financial hardship, please contact our patient financial services team to discuss potential payment plans or charity care options before the due date.

Late Fees: A late fee of 1.5% per month will be applied to balances remaining unpaid after 30 days from the invoice date, in accordance with Illinois state regulations.

Authorized Signature
Dr. Michael Ross, MD, FACR
Chief Radiologist
Windy City Advanced Radiology Received By (Patient)
Date Received: _________________
Signature: ____________________ ⬇️ Download as DOCX Edit online as DOCX

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