Quotation Estimate Doctor General Practitioner in United States Los Angeles –Free Word Template Download with AI
4820 Wilshire Boulevard, Suite 310, Los Angeles, California 90036, United States
Phone: (213) 555-0147 | Email: [email protected]
CA Medical License: D-48291 | NPI: 1740829365
Quotation EstimateQuotation Details
Quotation No.: QTE-2025-LA-04872
Date Issued: June 12, 2025
Valid Until: July 12, 2025 (30 days)
Prepared By: Dr. Margaret Chen, MD, FACP
Specialty: Doctor General Practitioner
Location: United States, Los Angeles, CA
Client / Patient Information
Name: Mr. Jonathan R. Whitfield
Address: 1247 Sunset Blvd, Apt 5B, Los Angeles, CA 90026
Phone: (323) 555-8821
Email: [email protected]
Insurance Provider: Blue Shield of California
Policy No.: BSC-9928471
Important Notice: This Quotation Estimate has been prepared by our Doctor General Practitioner team at Westside Family Medicine & Primary Care, located in the heart of United States Los Angeles. All pricing reflects current 2025 fee schedules for primary care services rendered in the Los Angeles metropolitan area. This document is a good-faith estimate and does not constitute a binding contract until formally accepted by both parties.The following Quotation Estimate outlines the comprehensive primary care services that our Doctor General Practitioner, Dr. Margaret Chen, will provide to the patient listed above. All services are performed in compliance with California State Board of Medicine regulations and applicable federal healthcare standards within the United States Los Angeles jurisdiction.
| # | Service Description | CPT Code | Qty | Unit Price (USD) | Estimated Total (USD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Annual Physical Examination by Doctor General Practitioner (includes history review, vital signs, full body assessment, and discussion of findings) | 99396 | 1 | $285.00 | $285.00 |
| 2 | Cervical/Pelvic and Prostate Screening (age-appropriate preventive screening per USPSTF guidelines) | 99397 | 1 | $195.00 | $195.00 |
| 3 | Complete Blood Count (CBC) with Differential – in-house laboratory | 85027 | 1 | $62.00 | $62.00 |
| 4 | Comprehensive Metabolic Panel (CMP) – in-house laboratory | 80053 | 1 | $78.00 | $78.00 |
| 5 | Lipid Panel (Fasting) – cholesterol and triglyceride assessment | 80061 | 1 | $54.00 | $54.00 |
| 6 | Hemoglobin A1c (HbA1c) – diabetes screening | 83036 | 1 | $48.00 | $48.00 |
| 7 | Thyroid Stimulating Hormone (TSH) – thyroid function screening | 84443 | 1 | $42.00 | $42.00 |
| 8 | Urinalysis with Microscopy | 81001 | 1 | $38.00 | $38.00 |
| 9 | Resting Electrocardiogram (ECG/EKG) – 12-lead | 93000 | 1 | $125.00 | $125.00 |
| 10 | Chest X-Ray (PA and Lateral views) – radiology referral within Los Angeles network | 71046 | 1 | $185.00 | $185.00 |
| 11 | Immunizations: Influenza (annual) + Tdap booster + Pneumococcal (PCV13) | 90658/90713/90670 | 3 | $45.00 | $135.00 |
| 12 | Follow-up Consultation (30 minutes) – review of lab results, treatment plan, and lifestyle counseling by Doctor General Practitioner | 99214 | 1 | $165.00 | $165.00 |
| 13 | Health Risk Assessment and Personalized Wellness Plan (written report, 15 pages minimum) | 99401 | 1 | $95.00 | $95.00 |
| 14 | Administrative and Coordination Fee (scheduling, insurance verification, records management, and patient portal setup) | N/A | 1 | $50.00 | $50.00 |
| Subtotal (All Services) | $1,657.00 |
| Estimated Insurance Coverage (Blue Shield of California – 80% PPO) | -$1,325.60 |
| Patient Responsibility (20% Co-pay / Co-insurance) | $331.40 |
| Annual Deductible Remaining (per insurance statement) | $1,200.00 |
| Estimated Patient Out-of-Pocket Total | $1,531.40 |
Terms and Conditions of This Quotation Estimate
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, pricing may be adjusted to reflect changes in the Doctor General Practitioner fee schedule, laboratory costs, or applicable Los Angeles County healthcare regulations.
- All services listed herein will be performed by or under the direct supervision of Dr. Margaret Chen, MD, FACP, a licensed Doctor General Practitioner in the State of California, United States. Any substitution of providers will require prior written consent from the patient.
- Payment is due within thirty (30) days of the date of service. Our practice in United States Los Angeles accepts all major credit cards (Visa, Mastercard, American Express, Discover), HSA/FSA cards, and personal checks. A 1.5% monthly late fee will be applied to balances exceeding 60 days past due.
- This Quotation Estimate is an estimate only and does not guarantee final billing. Actual charges may differ based on additional services rendered during the visit, unexpected findings requiring further investigation, or changes in insurance adjudication.
- All medical records, laboratory results, and imaging obtained through this engagement are the property of Westside Family Medicine & Primary Care and are maintained in compliance with HIPAA (Health Insurance Portability and Accountability Act) and California Confidentiality of Medical Information Act (CMIA) regulations.
- The patient acknowledges that this Quotation Estimate does not constitute a guarantee of specific medical outcomes. The Doctor General Practitioner will exercise reasonable medical judgment in the course of treatment and may recommend additional or alternative services as clinically indicated.
- Any disputes regarding this Quotation Estimate or subsequent billing should be directed to the practice manager at (213) 555-0147, ext. 2, or in writing to the address listed above. The practice is located in the City of Los Angeles, County of Los Angeles, State of California, United States of America.
- This document is governed by the laws of the State of California. Any legal proceedings arising from this Quotation Estimate shall be conducted in the Superior Court of Los Angeles County, United States.
Prepared and Authorized By:
Dr. Margaret Chen, MD, FACP
Doctor General Practitioner, Westside Family Medicine & Primary Care
Los Angeles, California, United States
Signature: ___________________________
Date: ___________________________
Accepted By (Patient / Authorized Representative):
Name: ___________________________
Relationship to Patient: ___________________________
Signature: ___________________________
Date: ___________________________
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT