Invoice Surgeon in Brazil Brasília –Free Word Template Download with AI
Advanced Surgical Solutions
Address: SIA Trecho 4, Lote 570, Asa Norte
Brasília, DF - Brazil, CEP: 71200-030
Phone: +55 (61) 3333-4444
Email: [email protected]
CNPJ: 12.345.678/0001-90
Invoice Number: INV-2024-0892
Date of Issue: October 24, 2024
Due Date: November 24, 2024
Payment Terms: Net 30 Days
Billed To:
Patient Name: João Silva Santos
CPF: 123.456.789-00
Address: SQS 308, Bloco A, Apt 402, Asa Sul
City: Brasília, DF - Brazil, CEP: 70366-590
Insurance Provider: Unimed Brasília
Policy Number: UNI-987654321
Description of Surgical Services Rendered
This invoice details the professional fees and associated costs for surgical procedures performed by our specialized surgeon team in Brasília, Brazil. All services comply with the regulations set forth by the Federal Council of Medicine (CFM) and local health authorities.
| Item # | Description of Service | Procedure Code (CBHPM) | Date of Service | Quantity | Unit Price (BRL) | Total (BRL) |
|---|---|---|---|---|---|---|
| 1 | Pre-operative Consultation and Assessment by Surgeon | 30101.03-0 | Oct 10, 2024 | 1 | R$ 450.00 | R$ 450.00 |
| 2 | Laparoscopic Cholecystectomy (Gallbladder Removal) | 30303.04-5 | Oct 15, 2024 | 1 | R$ 8,500.00 | R$ 8,500.00 |
| 3 | Surgeon's Professional Fee for Primary Procedure | 30303.05-3 | Oct 15, 2024 | 1 | R$ 4,200.00 | R$ 4,200.00 |
| 4 | Assistant Surgeon Fee | 30303.06-1 | Oct 15, 2024 | 1 | R$ 1,800.00 | R$ 1,800.00 |
| 5 | Anesthesia Services (General) | 30105.02-0 | Oct 15, 2024 | 1 | R$ 2,100.00 | R$ 2,100.00 |
| 6 | Operating Room Usage Fee (3 Hours) | 30102.01-0 | Oct 15, 2024 | 3 | R$ 900.00 | R$ 2,700.00 |
| 7 | Surgical Supplies and Implants | 30103.04-5 | Oct 15, 2024 | 1 | R$ 1,250.00 | R$ 1,250.00 |
| 8 | Post-operative Follow-up Consultation | 30101.04-8 | Oct 22, 2024 | 1 | R$ 350.00 | R$ 350.00 |
| Subtotal: | R$ 21,350.00 |
| Discount (Insurance Coverage): | - R$ 15,000.00 |
| Out-of-Pocket Amount: | R$ 6,350.00 |
| TOTAL DUE: | R$ 6,350.00 |
Important Notes and Payment Instructions:
1. This invoice is issued in accordance with Brazilian tax regulations and the standards of the Federal Council of Medicine (CFM). All surgical procedures were performed by licensed surgeons registered with the Regional Council of Medicine of the Federal District (CRM-DF).
2. Payment is due within 30 days of the invoice date. Late payments may incur a penalty of 2% plus interest of 1% per month, as per Brazilian consumer law.
3. For bank transfer payments, please use the following details:
- Bank: Banco do Brasil
- Agency: 1234-5
- Account Number: 98765-4
- Account Holder: Centro Cirúrgico Brasília Ltda.
- PIX Key: [email protected]
4. Please include the invoice number (INV-2024-0892) as the payment reference.
5. If you have any questions regarding this invoice or the surgical services provided, please contact our billing department at +55 (61) 3333-4444 or email [email protected].
6. This document serves as an official record of the surgical services rendered in Brasília, Brazil, and may be required for insurance reimbursement or tax purposes.
Authorized by:
Dr. Carlos Eduardo Mendes
Lead Surgeon
CRM-DF: 12345
Received by:
___________________________
Patient Signature
Date: _______________
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