Quotation Estimate Doctor General Practitioner in United States New York City –Free Word Template Download with AI
Doctor General Practitioner Services — United States New York City
Provider Information
Dr. Margaret E. Whitfield, M.D., F.A.C.P.
Doctor General Practitioner — Board Certified
Manhattan Primary Care Associates
1420 Lexington Avenue, 18th Floor
New York City, New York 10028
United States of America
Phone: (212) 555-0187
Email: [email protected]
NPI: 1497832651
NY State Medical License: 29A48731
Client / Patient Information
Mr. Jonathan R. Caldwell
Resident, New York City, NY 10019
United States of America
Phone: (917) 555-0342
Email: [email protected]
Insurance: Aetna PPO — Member ID: AET-88234-7719
Date of Birth: 03/14/1979
| Quotation No. | Date of Issue | Valid Until | Service Location |
|---|---|---|---|
| QTE-2025-00487 | June 12, 2025 | July 12, 2025 | New York City, NY — United States |
This Quotation Estimate is issued by Dr. Margaret E. Whitfield, a licensed Doctor General Practitioner operating in the United States New York City, to provide Mr. Jonathan R. Caldwell with a comprehensive, itemized financial projection for the full scope of primary care medical services to be rendered over the upcoming twelve-month period. This document serves as a binding cost estimate for the Doctor General Practitioner services described herein and is prepared in accordance with the billing standards established by the New York State Department of Health and the applicable fee schedules of the United States healthcare system. All pricing reflects current 2025 rates for a Doctor General Practitioner practice located in the metropolitan area of New York City, New York, United States.
The following Doctor General Practitioner services are included in this Quotation Estimate. Each service is performed by Dr. Whitfield or her credentialed staff at the Manhattan Primary Care Associates clinic in New York City, United States. The Doctor General Practitioner scope encompasses preventive medicine, acute illness management, chronic disease monitoring, diagnostic ordering, and patient education as standard components of primary care in the United States New York City healthcare environment.
| # | Service Description | CPT Code | Frequency | Unit Price (USD) | Estimated Total (USD) |
|---|---|---|---|---|---|
| 1 | Annual Comprehensive Physical Examination — Doctor General Practitioner | 99397 | 1x / year | $285.00 | $285.00 |
| 2 | Established Patient Office Visit (Level 4) — Doctor General Practitioner | 99214 | 4x / year | $210.00 | $840.00 |
| 3 | Chronic Disease Management (Hypertension & Type 2 Diabetes) — Doctor General Practitioner | 99490 | 12x / year | $95.00 | $1,140.00 |
| 4 | Point-of-Care Laboratory Panel (CBC, CMP, HbA1c, Lipid) — Doctor General Practitioner | 80053 / 83036 | 4x / year | $165.00 | $660.00 |
| 5 | Electrocardiogram (12-Lead ECG) — Doctor General Practitioner | 93000 | 1x / year | $120.00 | $120.00 |
| 6 | Immunizations (Influenza, Tdap, Pneumococcal) — Doctor General Practitioner | 90658 / 90713 | 1x / year | $145.00 | $145.00 |
| 7 | Telehealth Follow-Up Consultation — Doctor General Practitioner | 99441 | 6x / year | $85.00 | $510.00 |
| 8 | Prescription Refills & Medication Reconciliation — Doctor General Practitioner | 99211 | 8x / year | $45.00 | $360.00 |
| 9 | Referral Coordination & Specialist Liaison (New York City Network) — Doctor General Practitioner | 99495 | 2x / year | $75.00 | $150.00 |
| 10 | Patient Portal Access & Electronic Health Record Management — Doctor General Practitioner | Admin | 12x / year | $12.00 | $144.00 |
| Description | Amount (USD) | Notes |
|---|---|---|
| Subtotal — All Doctor General Practitioner Services | $4,354.00 | Annual estimate |
| Applicable New York City Sales Tax (8.875%) | $386.42 | NYC rate, United States |
| Insurance Adjustment (Aetna PPO — Estimated 70% coverage) | -$3,047.80 | Subject to deductible |
| Patient Estimated Out-of-Pocket Responsibility | $1,692.62 | Annual, United States |
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, the Doctor General Practitioner reserves the right to revise pricing in accordance with current New York City medical fee schedules.
- All services listed herein are to be performed at the Doctor General Practitioner office located at 1420 Lexington Avenue, New York City, New York, United States, unless otherwise specified for telehealth consultations.
- The estimated insurance adjustment is based on the Aetna PPO plan in effect as of the date of this Quotation Estimate. Actual reimbursement may vary based on deductible status, out-of-network provisions, or plan changes during the coverage period in the United States.
- This Quotation Estimate does not include emergency department visits, inpatient hospitalization, surgical procedures, or specialist consultations beyond the referral coordination fee listed in Item 9.
- Dr. Whitfield, as a Doctor General Practitioner licensed in the State of New York, United States, adheres to all HIPAA privacy regulations and New York State medical board standards of care.
- Payment for services rendered is due within thirty (30) days of the date of service. The Doctor General Practitioner practice accepts all major credit cards, HSA/FSA cards, and electronic bank transfers.
- Any services not explicitly listed in this Quotation Estimate will be billed at the Doctor General Practitioner's standard New York City fee schedule and will be communicated to the patient prior to rendering.
- This Quotation Estimate is a good-faith financial projection and does not constitute a guarantee of final charges. Actual costs may differ based on clinical findings, additional diagnostic needs, or changes in the patient's health status during the coverage year.
By signing below, the patient acknowledges receipt of this Quotation Estimate for Doctor General Practitioner services in New York City, United States, and authorizes Dr. Margaret E. Whitfield and the Manhattan Primary Care Associates practice to proceed with the outlined scope of care. The patient confirms understanding of the estimated out-of-pocket costs and the terms stated above.
Patient Signature — Mr. Jonathan R. Caldwell
Date
Doctor General Practitioner — Dr. Margaret E. Whitfield, M.D.
Date
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