Quotation Estimate Doctor General Practitioner in United States Chicago –Free Word Template Download with AI
Provider Information
Dr. Margaret E. Sullivan, MD, FACP
Doctor General Practitioner
Lakeview Medical Associates
1420 N. Lake Shore Drive, Suite 310
Chicago, Illinois 60610
United States
Phone: (312) 555-0187
Email: [email protected]
Illinois Medical License No. 231.004872
Client / Patient Information
Mr. James R. Whitfield
2847 W. Belmont Avenue
Chicago, Illinois 60657
United States
Phone: (773) 555-0342
Insurance: Blue Cross Blue Shield of Illinois
Policy No. BCBS-IL-88291044
Group No. GRP-2025-1173
This Quotation Estimate is issued by Dr. Margaret E. Sullivan, a licensed Doctor General Practitioner operating in the United States Chicago metropolitan area, to provide a detailed financial projection for the comprehensive primary care services to be rendered to the above-named client during the period of July 1, 2025 through June 30, 2026. All services will be delivered in accordance with the standards established by the Illinois Department of Financial and Professional Regulation and the American Medical Association guidelines applicable to general practice in the United States Chicago region.
| # | Service Description | Frequency | Unit Cost (USD) | Estimated Qty | Subtotal (USD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Annual Physical Examination by Doctor General Practitioner, including full blood panel, urinalysis, and cardiovascular screening | Annual | $385.00 | 1 | $385.00 |
| 2 | Routine Office Consultation (30-minute visit) with Doctor General Practitioner for ongoing health management | Quarterly | $225.00 | 4 | $900.00 |
| 3 | Preventive Health Screening: Lipid Panel, HbA1c, Thyroid Function, and Complete Metabolic Panel | Semi-Annual | $145.00 | 2 | $290.00 |
| 4 | Immunization Administration and Vaccination Counseling (Seasonal Influenza, Tdap, Pneumococcal as indicated) | As Needed | $65.00 | 3 | $195.00 |
| 5 | Electrocardiogram (ECG) and Blood Pressure Monitoring with Doctor General Practitioner interpretation | Annual | $120.00 | 1 | $120.00 |
| 6 | Chronic Disease Management Plan (Hypertension and Type 2 Diabetes) including medication review and dosage adjustments | Monthly | $95.00 | 12 | $1,140.00 |
| 7 | Telehealth Follow-Up Consultation with Doctor General Practitioner (15-minute virtual visit via HIPAA-compliant platform) | As Needed | $85.00 | 4 | $340.00 |
| 8 | Referral Coordination and Specialist Liaison Services within the United States Chicago healthcare network (Rush University, Northwestern Memorial, or University of Chicago Medicine) | As Needed | $55.00 | 2 | $110.00 |
| 9 | Health Education and Lifestyle Counseling Session (Nutrition, Exercise, Stress Management) conducted by Doctor General Practitioner | Quarterly | $75.00 | 4 | $300.00 |
| 10 | Annual Health Summary Report and Medical Records Update filed with client and primary insurance carrier | Annual | $45.00 | 1 | $45.00 |
| Subtotal (All Services) | $3,825.00 |
| Applicable Illinois State Tax (0% for medical services) | $0.00 |
| Insurance Co-Pay / Co-Insurance Deduction (Est. 20%) | -$765.00 |
| Estimated Patient Responsibility | $3,060.00 |
- This Quotation Estimate is a good-faith financial projection and does not constitute a binding contract. Final charges may vary based on clinical findings, additional diagnostic testing, or changes in the scope of care determined by the Doctor General Practitioner during the treatment period.
- All services described herein will be performed at the Lakeview Medical Associates facility located in Chicago, Illinois, United States, or via approved telehealth platforms as specified in the itemized breakdown above.
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. After the expiration date of July 12, 2025, the Doctor General Practitioner reserves the right to revise pricing based on current fee schedules and insurance contract terms.
- Payment is due within thirty (30) days of the date of service. The practice accepts all major credit cards, HSA/FSA accounts, and direct insurance billing through Blue Cross Blue Shield of Illinois and other in-network United States Chicago providers.
- Dr. Margaret E. Sullivan, MD, is a board-certified Doctor General Practitioner licensed by the State of Illinois. All services comply with the Health Insurance Portability and Accountability Act (HIPAA), the Illinois Patient Privacy Act, and the standards of the American College of Physicians.
- Any services not explicitly listed in this Quotation Estimate, including emergency care, additional laboratory work, imaging studies, or specialist consultations beyond the referral coordination fee, will be billed separately at the Doctor General Practitioner's standard fee schedule.
- This estimate reflects the prevailing medical service rates in the United States Chicago metropolitan area for the 2025–2026 billing cycle and is subject to annual adjustment in accordance with the practice's published fee schedule.
- The client acknowledges that this Quotation Estimate is for informational and planning purposes only and does not guarantee insurance coverage. The client is responsible for verifying benefits with their insurance provider prior to the commencement of services.
Prepared by:
Dr. Margaret E. Sullivan, MD, FACPDoctor General Practitioner
Lakeview Medical Associates, Chicago, IL
Date: _______________
Client Acknowledgment:
James R. WhitfieldPatient / Client
Chicago, Illinois, United States
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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