Invoice Surgeon in Israel Jerusalem –Free Word Template Download with AI
42 King George Street, Jerusalem, Israel
Phone: +972-2-555-0199 | Email: [email protected]
VAT ID: 512345678 | Medical License: IL-SURG-9988
Invoice #: JSC-2023-10-455
Date: October 24, 2023
Due Date: November 24, 2023
From (Provider)
Dr. David Cohen, MD, FACS
Board-Certified General & Laparoscopic Surgeon
Jerusalem Advanced Surgical Center
Jerusalem, Israel
Bill To (Patient/Insurer)
Mr. Jonathan Levy
15 Rehov HaYehudim, Jerusalem, Israel
ID Number: 123456789
Insurance Provider: Maccabi Healthcare Services
Policy Number: MAC-99887766
| # | Description of Surgical Services | Date of Service | Unit Price (ILS) | Total (ILS) |
|---|---|---|---|---|
| 1 | Pre-Operative Surgical Consultation: Comprehensive evaluation by the surgeon in Jerusalem, including review of medical history, physical examination, and surgical planning for laparoscopic cholecystectomy. | Oct 10, 2023 | 850.00 | 850.00 |
| 2 | Laparoscopic Cholecystectomy (CPT 47601): Minimally invasive surgical removal of the gallbladder performed by Dr. Cohen. Includes surgical time, anesthesia coordination, and use of advanced laparoscopic equipment at the Jerusalem facility. | Oct 15, 2023 | 12,500.00 | 12,500.00 |
| 3 | Operating Room Facility Fees: Usage of sterile surgical suite, nursing staff, and medical supplies required for the procedure in accordance with Israeli Ministry of Health standards. | Oct 15, 2023 | 4,200.00 | 4,200.00 |
| 4 | Post-Operative Pathology Analysis: Histological examination of the removed gallbladder tissue to confirm diagnosis and rule out malignancy. | Oct 16, 2023 | 650.00 | 650.00 |
| 5 | Post-Operative Follow-Up Visit: Wound check, suture removal (if applicable), and assessment of recovery progress by the surgeon. | Oct 22, 2023 | 450.00 | 450.00 |
Important Notes & Payment Terms:
- Currency: All amounts are listed in Israeli New Shekels (ILS).
- Payment Deadline: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge as per Israeli commercial law.
- Insurance: This invoice has been submitted to the patient's primary insurance provider. The patient is responsible for any co-payments, deductibles, or non-covered services as outlined in their policy.
- Disputes: Any discrepancies regarding the surgeon's fees or facility charges must be reported in writing within 14 days of receipt of this invoice.
- Medical Records: A copy of the operative report and discharge summary is available upon request from the Jerusalem Advanced Surgical Center medical records department.
- Bank Transfer Details:
Bank: Bank Hapoalim, Jerusalem Branch
Account Name: Jerusalem Advanced Surgical Center Ltd.
Account Number: 998877665
SWIFT Code: POALILIT
Dr. David Cohen, MD Patient Acknowledgement
Mr. Jonathan Levy ⬇️ Download as DOCX Edit online as DOCX
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