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Medical Invoice

This medical invoice summarizes services provided to Elsa Tillman by Dr. Theresa Moorman and Beverly Hospital. It includes charges for various medical tests and procedures totaling $57,764 with a sales tax of $1,600, for a total due of $54,344. The invoice is due for payment within 2 days, with a 2% per day late fee applied to unpaid balances. Payment can be made via credit card under the name of Mrs. Trauma or via bank wire transfer with account details provided.

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Aditya Jagtap
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2K views3 pages

Medical Invoice

This medical invoice summarizes services provided to Elsa Tillman by Dr. Theresa Moorman and Beverly Hospital. It includes charges for various medical tests and procedures totaling $57,764 with a sales tax of $1,600, for a total due of $54,344. The invoice is due for payment within 2 days, with a 2% per day late fee applied to unpaid balances. Payment can be made via credit card under the name of Mrs. Trauma or via bank wire transfer with account details provided.

Uploaded by

Aditya Jagtap
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

MEDICAL INVOICE

Bill From Bill To Invoice No. 34566755


Name: DR. Theresa MOORMAN Name: Elsa Tillman
Company Name: Beverly Hospital Street Address: Old England Rd, Invoice Date: 2010-02-26
Hospital Newton, MA 0246
Street Address: 85 Herrick St, USA Due Date: 2010-02-28
Beverly, MA 01915, United States Phone: 8337363236
Phone: +1 617-243-6000

Medical Services Performed Rate Total


Head Computed Tomography Scan $400 $4000
Rectal Examination $100 $1000
Neurologic Examination $1659 $1659
Blood test $1200 $1200
Chest X-ray $2800 $5600
Intensive Medical care $15000 $300000
CAT Scan (2) $3000 $6000
Pelvis Imaging $2000 $2000
Medication-on-admission (Prozac, tetracycline) $1137 $1137
Medication (Tylenol, Motrin) $48 $48
Serum and Urine Examination $100 $100
Subtotal $57764
Sales Tax $1600
Other
Total $54344

Terms and Conditions

Thank you for your business. Please send payment within 2 days of receiving this invoice. There will be a
2% per day on late invoices.

Page 1 of 3
Please Choose a Payment Type

Credit Card

☒ Visa ☐ MasterCard ☐ Discover ☐ American Express

Cardholder Name: Mrs. TRAUMA


Account/CC Number: 0473626227272
Expiration Date : 05 /29
CVV 087
Zip Code : 46379

I authorize the above named business/individual to charge the credit card indicated in
this authorization form according to the terms outlined above. This payment
authorization is for the goods/services described above, for the amount indicated above
only, and is valid for one (1) time use only. I certify that I am an authorized user of this
credit card and that I will not dispute the payment with my credit card company; so long
as the transaction corresponds to the terms indicated in this form.

SIGNATURE : Mrs. TRAUMA _________________________ DATE :


(cardholder name)

Bank Wire

Name on Bank Account: _________________________


Street Address: _________________________
Bank Name: _________________________
Account Number: _________________________
Routing Number: _________________________
Account Type: _________________________

Page 2 of 3
Email: __________________________

Page 3 of 3

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