Invoice Surgeon in India Bangalore –Free Word Template Download with AI
Senior Consultant Surgeon
Department of General & Laparoscopic Surgery
Fortis Hospital, Bannerghatta Road
Bangalore, Karnataka, India - 560076
Reg No: KMC/2005/12345
GSTIN: 29ABCDE1234F1Z5
Phone: +91-80-1234-5678
Email: [email protected]
Invoice No: INV-BLR-2023-0892
Date: October 24, 2023
Due Date: November 07, 2023
Ref: OPD-REG-44521
Bill To (Patient Details)
Name: Mr. Vikram Singh
Age/Gender: 45 Years / Male
Address: 12, Indiranagar 4th Block,
Bangalore, Karnataka, India - 560038
Insurance Provider: Star Health & Allied Insurance
Policy Number: SHAI-99887766
Group ID: CORP-BLR-001
Contact: +91-98765-43210
Procedure Summary
Date of Surgery: October 20, 2023
Procedure Performed: Laparoscopic Cholecystectomy (Removal of Gallbladder)
Anesthesia: General Anesthesia
Operating Surgeon: Dr. Arjun Rao
Assisting Surgeon: Dr. Priya Menon
Anesthesiologist: Dr. Suresh Kumar
Itemized Charges
| Description of Service | HSN/SAC Code | Qty | Rate (INR) | Amount (INR) |
|---|---|---|---|---|
| Surgeon's Professional Fee (Laparoscopic Cholecystectomy) | 999511 | 1 | 45,000.00 | 45,000.00 |
| Assisting Surgeon Fee | 999511 | 1 | 10,000.00 | 10,000.00 |
| Anesthesiologist Fee | 999511 | 1 | 8,000.00 | 8,000.00 |
| Operation Theatre Charges (4 Hours) | 999511 | 1 | 25,000.00 | 25,000.00 |
| Laparoscopic Consumables & Disposables | 999511 | 1 | 12,500.00 | 12,500.00 |
| Post-Operative Medication & Dressing | 999511 | 1 | 3,500.00 | 3,500.00 |
| Pathology Charges (Tissue Biopsy) | 999511 | 1 | 2,000.00 | 2,000.00 |
| Pre-Operative Investigations (Blood Work, ECG) | 999511 | 1 | 4,000.00 | 4,000.00 |
| ICU Monitoring (1 Night) | 999511 | 1 | 15,000.00 | 15,000.00 |
| General Ward Stay (2 Nights) | 999511 | 2 | 5,000.00 | 10,000.00 |
| Subtotal: | 135,000.00 INR |
| GST (18% on applicable services): | 24,300.00 INR |
| Total Amount Payable: | 159,300.00 INR |
Amount in words: One Hundred Fifty-Nine Thousand Three Hundred Indian Rupees Only.
Payment Instructions
Please make the payment within 15 days of the invoice date. Late payments may attract interest as per hospital policy.
Bank Transfer Details:
Bank Name: HDFC Bank
Branch: Bannerghatta Road, Bangalore
Account Name: Fortis Healthcare Ltd.
Account Number: 50100123456789
IFSC Code: HDFC0001234
UPI ID: fortis.bangalore@hdfcbank
Cheque Details:
Please make cheques payable to "Fortis Healthcare Ltd." and mention the Invoice Number on the reverse.
Terms and Conditions
- This invoice is issued in accordance with the Goods and Services Tax (GST) Act, 2017, India.
- Services rendered are subject to the medical standards and protocols of the hospital located in Bangalore, India.
- Insurance claims should be processed directly with the respective insurance provider using this invoice and the attached medical reports.
- Any discrepancies in the billing must be reported within 7 days of receiving this invoice.
- The Surgeon's fee is non-refundable once the procedure has been scheduled and performed.
- This document serves as a legal record of the financial transaction between the patient and the healthcare provider.
Authorized Signatory
Billing Department
Dr. Arjun Rao
Senior Consultant Surgeon
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