Quotation Estimate Doctor General Practitioner in United States Miami –Free Word Template Download with AI
Doctor General Practitioner Services
United States Miami, Florida 33101
Quotation No.: QTE-MIA-2025-04872Date Issued: June 15, 2025
Valid Until: July 15, 2025 Provider: Dr. Elena Martinez, M.D.
Specialty: Doctor General Practitioner
Practice: Miami Comprehensive Family Medicine
Address: 1200 Biscayne Blvd, Suite 450, Miami, FL 33132
Phone: (305) 555-0198
Email: [email protected] Client / Patient Information
| Patient Name: | Mr. James R. Thompson |
| Address: | 845 Coral Way, Apt 12B, Miami, FL 33145, United States |
| Insurance Provider: | UnitedHealthcare – Plan ID: UHC-FL-88231 |
| Policy Number: | UHC-2025-4471829 |
| Referring Physician: | Dr. Alan Whitfield, M.D. – Cardiology, Baptist Health Miami |
This Quotation Estimate has been prepared by the undersigned Doctor General Practitioner to provide Mr. James R. Thompson with a comprehensive, itemized breakdown of anticipated medical services, diagnostic procedures, and follow-up care to be rendered at our practice located in United States Miami, Florida. This document serves as a formal financial projection and is not a binding contract. All costs listed herein are estimates based on current fee schedules, standard insurance coverage parameters, and the clinical assessment conducted during the initial consultation on June 10, 2025. The Doctor General Practitioner reserves the right to adjust this Quotation Estimate should the clinical course of treatment require additional interventions not anticipated at the time of this document's preparation.
Itemized Services and Estimated Costs| Item No. | Description of Service | Frequency | Estimated Cost (USD) |
|---|---|---|---|
| 1 | Comprehensive Initial Consultation with Doctor General Practitioner (60 minutes), including full medical history review, physical examination, and treatment plan formulation | One-time | $285.00 |
| 2 | Follow-up Consultation with Doctor General Practitioner (30 minutes) for progress monitoring and medication adjustment | Monthly x 6 | $165.00 each |
| 3 | Complete Blood Count (CBC) with Differential, Comprehensive Metabolic Panel (CMP), and Lipid Profile | One-time | $195.00 |
| 4 | 12-Lead Electrocardiogram (ECG/EKG) with Doctor General Practitioner interpretation | One-time | $120.00 |
| 5 | Chest X-Ray (PA and Lateral views) – performed at Miami Imaging Center, Biscayne Avenue | One-time | $210.00 |
| 6 | Thyroid Function Panel (TSH, Free T3, Free T4) | One-time | $95.00 |
| 7 | Prescription Medications – Lisinopril 10mg (90-day supply) and Metformin 500mg (90-day supply) | Monthly x 6 | $42.00 each |
| 8 | Annual Physical Examination with Doctor General Practitioner including age-appropriate preventive screenings (United States Miami standard panel) | One-time | $320.00 |
| 9 | Referral Coordination and Specialist Consultation Oversight (Cardiology follow-up at Baptist Health Miami) | One-time | $75.00 |
| 10 | Telehealth Follow-up Visit with Doctor General Practitioner (15 minutes) for minor adjustments or questions | As needed (max 3) | $85.00 each |
| Subtotal – One-Time Services | $1,105.00 |
| Subtotal – Recurring Monthly Services (6 months) | $1,452.00 |
| Subtotal – Telehealth Visits (3 visits) | $255.00 |
| Estimated Total (Before Insurance) | $2,812.00 |
| Estimated Insurance Coverage (UnitedHealthcare – 80% after deductible) | -$2,049.00 |
| Estimated Patient Responsibility | $763.00 |
- This Quotation Estimate is valid for thirty (30) days from the date of issuance. After the expiration date, all fees are subject to revision based on current Doctor General Practitioner fee schedules and applicable United States Miami healthcare regulations.
- All services will be performed in compliance with the Florida Board of Medicine standards and the Health Insurance Portability and Accountability Act (HIPAA) as enforced in the United States Miami metropolitan area.
- The Doctor General Practitioner will submit all applicable claims directly to UnitedHealthcare on behalf of the patient. The patient is responsible for any co-pays, deductibles, or coinsurance amounts as determined by the insurance plan.
- Should the clinical condition require services beyond those outlined in this Quotation Estimate, a revised estimate will be provided and must be approved in writing by the patient prior to additional procedures being performed.
- Cancellation of scheduled appointments must be made at least twenty-four (24) hours in advance to avoid a no-show fee of $75.00, consistent with standard practice policies in United States Miami medical offices.
- This Quotation Estimate does not constitute a guarantee of specific medical outcomes. The Doctor General Practitioner will exercise reasonable medical judgment in determining the most appropriate course of treatment.
- All payments are due within thirty (30) days of the date of service. Accepted payment methods include credit card, debit card, HSA/FSA cards, and personal check. A 1.5% monthly late fee will apply to balances exceeding the due date.
- This document is prepared in accordance with the Florida Department of Health regulations governing medical fee disclosure in the United States Miami region.
By signing below, the patient acknowledges receipt of this Quotation Estimate and authorizes the Doctor General Practitioner to proceed with the outlined services at the practice located in United States Miami. The patient confirms understanding that all costs are estimates and may vary based on clinical necessity and insurance adjudication.
Patient SignatureJames R. Thompson | Date: _______________ Doctor General Practitioner
Dr. Elena Martinez, M.D. | Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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