Invoice Surgeon in United States New York City –Free Word Template Download with AI
Board Certified General & Laparoscopic Surgeon
Manhattan Surgical Associates
100 East 57th Street, Suite 1200
New York, NY 10022
United States
Tel: (212) 555-0199
NPI: 1234567890
Invoice #: NY-2023-8842
Date: October 24, 2023
Due Date: November 24, 2023
Billed To (Patient)
Name: Jonathan P. Reynolds
Address: 45 West 67th Street, Apt 4B
City, State, Zip: New York, NY 10023
United States
DOB: 05/12/1978
Phone: (917) 555-0123
Insurance Information
Provider: Empire Blue Cross Blue Shield
Policy Holder: Jonathan P. Reynolds
Group Number: 99887766
Member ID: EBC-445566778
Referring Physician: Dr. Sarah Jenkins, Internal Medicine
Services Rendered in New York City
The following invoice details the professional fees for surgical services provided by Dr. Sterling at NewYork-Presbyterian Hospital, Manhattan Campus. All procedures were performed in accordance with the standards of care required in the State of New York.
| Date of Service | Description of Surgical Service | CPT Code | ICD-10 Code | Amount (USD) |
|---|---|---|---|---|
| Oct 10, 2023 | Pre-operative surgical consultation and evaluation in Manhattan office. | 99244 | K35.80 | $450.00 |
| Oct 15, 2023 | Laparoscopic cholecystectomy (gallbladder removal). Includes surgeon's professional fee, anesthesia coordination, and facility usage coordination within NYC. | 47562 | K80.20 | $8,500.00 |
| Oct 15, 2023 | Intraoperative cholangiography to visualize bile ducts during the procedure. | 47520 | K80.20 | $1,200.00 |
| Oct 16, 2023 | Post-operative hospital visit (Day 1) to monitor recovery and surgical site. | 99231 | Z48.81 | $350.00 |
| Oct 17, 2023 | Post-operative hospital visit (Day 2) and discharge planning. | 99232 | Z48.81 | $400.00 |
| Oct 24, 2023 | Follow-up surgical consultation in New York City office for wound check and suture removal. | 99243 | Z48.81 | $375.00 |
Payment Instructions
Payment is due within 30 days of the invoice date. Please make checks payable to Manhattan Surgical Associates and mail to the address listed in the header. For electronic payments, please contact our billing department at [email protected]. This invoice represents the balance due after insurance adjudication for services rendered in the United States, specifically within New York City.
Important Notice Regarding Surgeon Services
This invoice covers the professional fees of the attending surgeon only. Facility fees, anesthesia fees, and pathology fees are billed separately by their respective providers. As a medical practice operating in New York City, we adhere to all local, state, and federal billing regulations. If you have questions regarding the specific CPT codes or the necessity of the surgical procedure, please contact our patient advocacy team.
Disclaimer: This document is an official invoice for medical services. The information contained herein is confidential and protected under HIPAA regulations. Failure to pay the outstanding balance may result in the account being referred to a collection agency, which may affect your credit score. Dr. Alexander Sterling is a licensed physician in the State of New York. All surgical procedures were performed with the patient's informed consent. This invoice is valid for tax purposes in the United States. Please retain this document for your records. If you believe there is an error on this invoice, please notify us in writing within 60 days of receipt.
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