Invoice Radiologist in United States San Francisco –Free Word Template Download with AI
1234 Market Street, Suite 500
San Francisco, CA 94103
United States
Phone: (415) 555-0199
Email: [email protected]
NPI: 1234567890 | CA Medical License: R-12345
Invoice Number: INV-SF-2023-0892
Date Issued: October 24, 2023
Due Date: November 23, 2023
Service Period: October 1, 2023 - October 20, 2023
BILL TO:
Golden Gate Health Insurance Group
Attn: Accounts Payable Department
555 Montgomery Street, Floor 12
San Francisco, CA 94111
United States
Provider ID: GGHI-998877
PATIENT INFORMATION:
Name: John Doe
DOB: 05/12/1980
Policy Number: GGHI-POL-445566
Group Number: GGHI-GRP-112233
| Date | Description of Radiological Services | CPT Code | ICD-10 | Qty | Unit Price | Total |
|---|---|---|---|---|---|---|
| Oct 02, 2023 | Magnetic Resonance Imaging (MRI) of the Brain without contrast material. Performed by licensed Radiologist at our San Francisco facility. | 70553 | G43.909 | 1 | $1,200.00 | $1,200.00 |
| Oct 05, 2023 | Computed Tomography (CT) Scan of the Chest with contrast material. Detailed interpretation provided by attending Radiologist. | 71260 | J98.4 | 1 | $950.00 | $950.00 |
| Oct 08, 2023 | Diagnostic Mammography, bilateral. Screening and diagnostic evaluation conducted in compliance with California state regulations. | 77067 | Z12.31 | 1 | $450.00 | $450.00 |
| Oct 12, 2023 | Ultrasound of the Abdomen, complete. Real-time imaging and radiological assessment performed in San Francisco. | 76700 | K80.20 | 1 | $600.00 | $600.00 |
| Oct 15, 2023 | X-Ray of the Lumbar Spine, 2 views. Standard radiographic examination interpreted by board-certified Radiologist. | 72100 | M54.5 | 1 | $250.00 | $250.00 |
| Oct 18, 2023 | Professional Fee for Radiologist interpretation of complex MRI findings. Includes detailed written report and consultation. | 70553 | G43.909 | 1 | $350.00 | $350.00 |
| Subtotal: | $3,800.00 |
| California State Tax (if applicable): | $0.00 |
| Insurance Adjustment: | -$1,200.00 |
| Total Amount Due: | $2,600.00 |
Terms and Conditions
- Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge.
- All services were performed in accordance with the standards of the American College of Radiology (ACR) and California state medical board regulations.
- This Invoice is issued by Bay Area Advanced Radiology, a licensed medical imaging facility located in San Francisco, California, United States.
- Claims should be submitted electronically via HIPAA-compliant channels. Please reference the Invoice Number and Patient Policy Number.
- Any disputes regarding charges must be reported in writing within 15 days of receiving this Invoice.
- Our Radiologists are board-certified and adhere to the highest standards of patient care and diagnostic accuracy.
- For questions regarding this Invoice, please contact our billing department at (415) 555-0199 or email [email protected].
Authorized by:
Dr. Emily Chen, MD
Chief Radiologist
Bay Area Advanced Radiology
Received by:
__________________________
Name:
Date:
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