Invoice Surgeon in United States Miami –Free Word Template Download with AI
Miami Center for Advanced Surgical Arts
1000 Brickell Avenue, Suite 1400
Miami, FL 33131
United States
Phone: (305) 555-0199
Email: [email protected]
NPI: 1234567890 | FL MED LIC: ME12345678
INVOICE
Invoice Number: INV-2023-10-8842
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Procedure Date: October 15, 2023
BILL TO:
Mr. Jonathan Sterling
2400 Collins Avenue, Apt 5B
Miami Beach, FL 33139
United States
Phone: (305) 555-0144
PATIENT INFORMATION:
Name: Jonathan Sterling
Date of Birth: 05/12/1985
Insurance Provider: Blue Cross Blue Shield of Florida
Policy Number: BCBS-FL-99887766
Group Number: GRP-445566
Download and customize a professional Invoice Surgeon United States Miami Word template. Perfect for business, legal, and personal use. Editable and ready to boost your productivity. OF SURGICAL SERVICES RENDERED IN MIAMI, FLORIDA
The following invoice details the professional fees charged by the Surgeon for the surgical procedure, pre-operative consultations, and post-operative care provided at the Miami Center for Advanced Surgical Arts. All services were performed in accordance with the standards of the American Board of Surgery and local regulations within the United States.
| # | Description of Service / CPT Code | Date | Unit Price | Total Amount |
|---|---|---|---|---|
| 1 |
Pre-Operative Consultation & Surgical Planning CPT 99244 - Office/Outpatient Consultation Comprehensive evaluation of patient history, physical examination, and surgical risk assessment conducted in Miami. |
09/20/2023 | $450.00 | $450.00 |
| 2 |
Primary Surgical Procedure: Abdominoplasty CPT 15830 - Abdominoplasty Surgical removal of excess skin and fat from the abdomen, tightening of abdominal muscles. Performed by Dr. Rivera. |
10/15/2023 | $8,500.00 | $8,500.00 |
| 3 |
Secondary Procedure: Liposuction (Trunk) CPT 15876 - Liposuction, trunk Suction assisted lipectomy performed concurrently with the primary procedure. |
10/15/2023 | $2,200.00 | $2,200.00 |
| 4 |
Global Post-Operative Care Package Includes 90-day follow-up Includes all scheduled follow-up visits, wound checks, suture removal, and management of complications within the global period. |
10/15/2023 | $1,200.00 | $1,200.00 |
| 5 |
Medical Supplies & Garments Non-CPT / Out of Pocket Compression garments, surgical drains, and specialized dressings provided by the clinic. |
10/15/2023 | $350.00 | $350.00 |
| Subtotal: | $12,700.00 |
| Insurance Adjustment (Est.): | -$4,500.00 |
| Patient Responsibility: | $8,200.00 |
| Less: Deposit Paid (09/20/2023): | -$2,000.00 |
| TOTAL DUE: | $6,200.00 |
Payment Terms & Important Information:
- Currency: All amounts are listed in United States Dollars (USD).
- Due Date: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge.
- Accepted Payment Methods: We accept Visa, MasterCard, American Express, Discover, Cashier's Checks, and Wire Transfers. Personal checks are accepted only from local Miami-Dade County banks.
- Insurance: This invoice represents the Surgeon's professional fees. Facility fees and Anesthesiologist fees are billed separately by their respective providers.
- Disputes: Please contact our billing department at (305) 555-0199 within 10 days if you have any questions regarding this invoice.
- Privacy: In compliance with HIPAA regulations, this document contains protected health information. Please dispose of it securely.
Dr. Alejandro Rivera, MD
Date: 10/24/2023 Patient Signature (Acknowledgement)
__________________________
Date: ____________________ ⬇️ Download as DOCX Edit online as DOCX
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