Invoice Surgeon in Brazil São Paulo –Free Word Template Download with AI
Specialist in General and Laparoscopic Surgery
CRM-SP: 123.456 | RQE: 78.901
Av. Paulista, 1578, 12th Floor, Suite 1204
Bela Vista, São Paulo - SP, Brazil
CEP: 01310-200
Email: [email protected]
Phone: +55 (11) 3254-8899
Invoice Number: INV-2023-10-045
Date of Issue: October 24, 2023
Due Date: November 07, 2023
Currency: BRL (Brazilian Real)
Bill To (Patient)Name: Ana Carolina Silva
CPF: 123.456.789-00
Address: Rua Oscar Freire, 500, Apt 42
Jardins, São Paulo - SP, Brazil
CEP: 01426-001
Insurance / PayerProvider: Bradesco Saúde Premium
Policy Number: 9876543210
Group: 123456
Authorization Code: AUT-SP-998877
Description of Surgical Services Rendered| Item | Description / Procedure | Tabela Procedimentos (Code) | Unit Price (BRL) | Total (BRL) |
|---|---|---|---|---|
| 1 |
Pre-operative Consultation and Assessment Comprehensive evaluation of the patient's medical history, physical examination, and review of imaging studies (CT/MRI) to determine surgical eligibility and plan the intervention strategy. Includes discussion of risks and benefits. |
41011.03-0 | R$ 450,00 | R$ 450,00 |
| 2 |
Laparoscopic Cholecystectomy Surgical removal of the gallbladder via minimally invasive laparoscopic technique. Performed at Hospital Albert Einstein, São Paulo. Includes surgical time, technical skill, and intraoperative decision-making. |
40023.02-0 | R$ 4.500,00 | R$ 4.500,00 |
| 3 |
Post-operative Care and Follow-up Immediate post-surgical monitoring in the recovery room, wound inspection, and management of pain and nausea. Includes two scheduled follow-up visits to ensure proper healing and removal of sutures/staples if necessary. |
41020.01-0 | R$ 800,00 | R$ 800,00 |
| 4 |
Medical Report and Documentation Preparation of detailed surgical report (Operatório), discharge summary, and certification of leave from work (Afastamento) as required by Brazilian labor laws and insurance protocols. |
41015.05-0 | R$ 300,00 | R$ 300,00 |
Payment Instructions
Please remit payment within 15 days of the invoice date to avoid late fees.
Bank: Banco do Brasil S.A.
Agency: 1234-5
Account Number: 98765-4
Account Holder: Dr. Ricardo Mendes
CPF/CNPJ: 123.456.789-00
PIX Key: [email protected]
Note: Please include the Invoice Number (INV-2023-10-045) in the payment description.
Terms and Conditions1. This invoice represents the professional fees for surgical services rendered by Dr. Ricardo Mendes in São Paulo, Brazil. It does not include hospital facility fees, anesthesia fees, or laboratory costs, which are billed separately by the respective providers.
2. All prices are quoted in Brazilian Reais (BRL). In the event of payment in foreign currency, the exchange rate will be the "PTAX" rate published by the Central Bank of Brazil on the date of payment.
3. Late payments will incur a fine of 2% plus interest of 1% per month, in accordance with Brazilian consumer protection laws.
4. This document serves as a formal request for payment and a record of the medical procedures performed. It is valid for insurance reimbursement purposes.
5. Any disputes regarding this invoice must be raised within 30 days of receipt. The jurisdiction for any legal matters is the city of São Paulo, SP.
Authorized Signature
Dr. Ricardo Mendes
Surgeon
Received By
Date: _______________
Name: _______________
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