Invoice Surgeon in United States Houston –Free Word Template Download with AI
1200 Main Street, Suite 450
Houston, Texas 77002
United States
Phone: (713) 555-0199 | Fax: (713) 555-0198
Tax ID: 74-1234567
Service Provider (Surgeon)
Dr. Elena Rodriguez, MD, FACS
Board Certified General & Laparoscopic Surgeon
License No: TX-198234
NPI: 1234567890
Houston Premier Surgical Group
Bill To (Patient / Insurance)
Mr. James Anderson
4500 Westheimer Road, Apt 12B
Houston, Texas 77027
United States
Insurance: Blue Cross Blue Shield of Texas
Policy ID: BCBS-TX-998877
Group ID: GRP-554433
Statement of Surgical Services Rendered
This invoice represents the professional fees charged by the attending surgeon for the surgical procedure performed at the Houston Methodist Hospital on October 15, 2023. The procedure was conducted in accordance with the highest standards of medical practice within the United States healthcare system. The surgeon provided pre-operative consultation, the primary surgical intervention, and immediate post-operative care. This document serves as the official request for payment for the professional component of the surgery, separate from facility fees and anesthesia costs which are billed independently.
| CPT Code | Description of Service | Units | Unit Price | Total |
|---|---|---|---|---|
| 47562 | Laparoscopic cholecystectomy (gallbladder removal); with common duct exploration. Performed by the attending surgeon. | 1 | $4,500.00 | $4,500.00 |
| 99217 | Postoperative hospital or nursing facility care on the day of discharge. Comprehensive evaluation by the surgeon. | 1 | $850.00 | $850.00 |
| 99223 | Initial hospital care, per new patient, requiring a comprehensive history, examination, and high complexity medical decision making. | 1 | $600.00 | $600.00 |
| 99232 | Subsequent hospital care, per established patient, requiring a detailed interval history, focused examination, and moderate complexity medical decision making. | 2 | $400.00 | $800.00 |
| 99244 | Office or other outpatient consultation for a new or established patient, requiring a detailed history, detailed examination, and high complexity medical decision making. | 1 | $550.00 | $550.00 |
| 99024 | Postoperative follow-up visit(s) on a date(s) other than the day of surgery or the day after surgery. | 1 | $250.00 | $250.00 |
| Subtotal: | $7,550.00 |
| Tax (0% - Medical Exempt): | $0.00 |
| Insurance Adjustment (Est.): | -$2,550.00 |
| Total Amount Due: | $5,000.00 |
Payment Terms and Conditions
Payment Methods: We accept checks payable to "Houston Premier Surgical Group," major credit cards (Visa, MasterCard, Amex), and direct bank transfers.
Insurance Billing: If this invoice is being submitted to your insurance provider, please ensure all patient demographic information is accurate. The surgeon's office will submit this claim electronically to Blue Cross Blue Shield of Texas. Any remaining balance after insurance adjudication is the responsibility of the patient.
Late Fees: Payments not received within 30 days of the invoice date may be subject to a late fee of 1.5% per month on the outstanding balance.
Disputes: If you have any questions regarding the charges listed on this invoice, please contact our billing department at (713) 555-0199 within 10 days of receipt.
HIPAA Notice: This document contains Protected Health Information (PHI) as defined by the Health Insurance Portability and Accountability Act of 1996. Please handle with confidentiality.
Authorized By:
Dr. Elena Rodriguez, MD
Lead Surgeon
Received By:
__________________________
Date: ____________________
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