Invoice Radiologist in United States Los Angeles –Free Word Template Download with AI
1200 Wilshire Blvd, Suite 400
Los Angeles, CA 90017
United States
Phone: (213) 555-0199 | Fax: (213) 555-0198
Email: [email protected]
Tax ID / EIN: 94-1234567
Invoice Number: INV-2023-8842
Date Issued: October 24, 2023
Due Date: November 24, 2023
Payment Terms: Net 30
Bill To (Patient)
Name: Jonathan M. Sterling
Address: 4500 Sunset Blvd, Apt 12B
City, State, Zip: Los Angeles, CA 90027
Country: United States
Date of Birth: 05/12/1978
Phone: (323) 555-0142
Insurance Information
Provider: Blue Shield of California
Policy Number: BS-9988776655
Group Number: GRP-445566
Subscriber Name: Jonathan M. Sterling
Referring Physician: Dr. Sarah Jenkins, MD
Referring Facility: Cedars-Sinai Medical Center
| Date of Service | Description of Radiology Services | CPT Code | ICD-10 Code | Charges (USD) | Qty |
|---|---|---|---|---|---|
| Oct 20, 2023 | Magnetic Resonance Imaging (MRI) of the Lumbar Spine without contrast material. Performed at our Los Angeles facility. | 72148 | M54.5 | $1,250.00 | 1 |
| Oct 20, 2023 | Professional interpretation of MRI Lumbar Spine by Board-Certified Radiologist. | 72148-26 | M54.5 | $450.00 | 1 |
| Oct 21, 2023 | Computed Tomography (CT) Scan of the Chest with contrast material. Detailed analysis of thoracic structures. | 71260 | J98.4 | $980.00 | 1 |
| Oct 21, 2023 | Professional interpretation of CT Chest with contrast by Board-Certified Radiologist. | 71260-26 | J98.4 | $375.00 | 1 |
| Oct 22, 2023 | Diagnostic Ultrasound of the Abdomen, Complete. Evaluation of liver, gallbladder, pancreas, and kidneys. | 76700 | R10.9 | $650.00 | 1 |
| Oct 22, 2023 | Professional interpretation of Abdominal Ultrasound by Board-Certified Radiologist. | 76700-26 | R10.9 | $280.00 | 1 |
| Oct 23, 2023 | Mammography, Bilateral, Diagnostic. Detailed imaging for breast tissue evaluation. | 77065 | R50.9 | $550.00 | 1 |
| Oct 23, 2023 | Professional interpretation of Diagnostic Mammography by Board-Certified Radiologist. | 77065-26 | R50.9 | $225.00 | 1 |
Important Notes & Payment Instructions
Payment Methods: We accept Visa, MasterCard, American Express, Discover, and personal checks. For electronic payments, please visit our secure portal at pay.laadvancedradiology.com.
Insurance Claims: This invoice represents the patient's estimated responsibility after primary insurance processing. If you have not yet submitted your insurance claim, please do so immediately. Upon receipt of your Explanation of Benefits (EOB), we will adjust this invoice accordingly.
Late Fees: In accordance with California state regulations and our office policy, a late fee of 1.5% per month will be applied to any balance remaining unpaid after the due date of November 24, 2023.
Questions: If you have any questions regarding these charges or the services provided by our Radiologist team in Los Angeles, please contact our billing department at (213) 555-0199 between 8:00 AM and 5:00 PM PST, Monday through Friday.
Privacy: Your health information is protected under HIPAA regulations. This invoice contains protected health information (PHI) and should be handled with confidentiality.
Authorized Signature:
Dr. Michael Chen, MD, FACR
Chief Radiologist
LA Advanced Radiology Group
Patient Acknowledgement:
I acknowledge receipt of this invoice and understand my financial responsibility.
Signature: __________________________
Date: __________________________
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