Invoice Surgeon in United States Los Angeles –Free Word Template Download with AI
Board Certified Surgeons
1234 Wilshire Boulevard, Suite 500
Los Angeles, CA 90017, United States
Phone: (213) 555-0199 | Fax: (213) 555-0198
NPI: 1234567890 | CA Medical License: A123456
Invoice Number: INV-2023-8842
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Reference ID: LA-SURG-9921
BILL TO:
Blue Cross Blue Shield of California
P.O. Box 12345
Los Angeles, CA 90012
United States
Group Number: G-884210
Claim ID: BCBS-2023-5541
PATIENT INFORMATION:
Name: Johnathan Doe
Date of Birth: 05/12/1985
Member ID: 987654321
Address: 456 Sunset Blvd, Apt 4B, Los Angeles, CA 90026
Date of Service: October 15, 2023
Procedure Date: October 15, 2023
| CPT Code | Description of Surgical Services | Charges | Allowed Amount |
|---|---|---|---|
| 47562 | Laparoscopic cholecystectomy; with common duct exploration. Performed by Dr. Elena Rodriguez, MD, FACS at Cedars-Sinai Medical Center, Los Angeles, CA. | $4,500.00 | $3,200.00 |
| 00812 | Anesthesia for procedures on the biliary tract, including laparoscopic procedures. Administered in Los Angeles, United States. | $1,200.00 | $950.00 |
| 99223 | Initial hospital care, per day, for the evaluation and management of a new patient. Surgeon consultation regarding post-operative recovery. | $650.00 | $480.00 |
| 99232 | Subsequent hospital care, per day, for the evaluation and management of a patient. Follow-up visit by the attending surgeon. | $450.00 | $320.00 |
| 99024 | Postoperative management only; 30 days. Includes monitoring of surgical site and wound care instructions provided in Los Angeles. | $300.00 | $250.00 |
| 80047 | Comprehensive metabolic panel. Pre-operative laboratory testing required for surgical clearance. | $150.00 | $110.00 |
| 76700 | Ultrasound, abdominal, real time with image documentation. Diagnostic imaging performed prior to surgery. | $350.00 | $275.00 |
Payment Terms and Important Information:
This invoice represents the final accounting for surgical services rendered by Los Angeles Surgical Specialists. As a premier medical facility in the United States, we adhere to strict billing standards compliant with California state regulations and federal healthcare laws.
Payment Methods: Payments can be made via credit card (Visa, MasterCard, Amex), check, or electronic funds transfer. Please make checks payable to "Los Angeles Surgical Specialists."
Due Date: The outstanding balance of $1,585.00 is due by November 24, 2023. Late payments may incur a 1.5% monthly finance charge.
Disputes: If you believe there is an error on this invoice, please contact our billing department within 30 days of the invoice date. Please reference Invoice Number INV-2023-8842 in all correspondence.
Privacy Notice: In accordance with HIPAA regulations, your medical information is kept confidential. This invoice contains protected health information and should be handled securely.
Contact: For questions regarding this invoice, please call our billing office at (213) 555-0199 between 8:00 AM and 5:00 PM PST, Monday through Friday.
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT