Invoice Ophthalmologist in Belgium Brussels –Free Word Template Download with AI
Avenue Louise 250
1050 Brussels, Belgium
Tel: +32 2 555 0199
Email: [email protected]
Invoice Number: INV-2023-10-045
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Provider Information
Entity: Dr. Jean-Pierre Dubois Ophthalmology Practice
Address: Avenue Louise 250, 1050 Brussels, Belgium
VAT Number: BE0678.901.234
Bank Account (IBAN): BE68 5390 0754 7034
BIC: KREDBEBB
Bill To
Patient Name: Ms. Elena Rossi
Address: Rue de la Loi 155, 1040 Brussels, Belgium
National Register Number: 850612 123 45 67
Insurance Provider: Mutualité Chrétienne / Christelijke Mutualiteit
Policy Number: MC-BRU-998877
Services Rendered
The following ophthalmological services were provided at our clinic in Brussels, Belgium, in accordance with the Belgian Tariff of Medical Fees.
| Date | Description of Ophthalmological Service | Code | Qty | Unit Price (€) | Total (€) |
|---|---|---|---|---|---|
| Oct 24, 2023 | Comprehensive Ophthalmological Examination including visual acuity testing, refraction, and slit-lamp biomicroscopy. | 10.01 | 1 | 45.00 | 45.00 |
| Oct 24, 2023 | Intraocular Pressure Measurement (Tonometry) to assess glaucoma risk. | 10.05 | 1 | 15.00 | 15.00 |
| Oct 24, 2023 | Dilated Fundus Examination of the retina and optic nerve head. | 10.08 | 1 | 25.00 | 25.00 |
| Oct 24, 2023 | Optical Coherence Tomography (OCT) scan of the macula and optic nerve. | 10.15 | 1 | 85.00 | 85.00 |
| Oct 24, 2023 | Prescription for corrective lenses (glasses) based on refraction results. | 10.02 | 1 | 10.00 | 10.00 |
| Oct 24, 2023 | Consultation regarding dry eye syndrome management and treatment plan. | 10.03 | 1 | 30.00 | 30.00 |
Important Notes & Terms
Payment Terms: Payment is due within 30 days of the invoice date. Please include the invoice number (INV-2023-10-045) as a reference when making your bank transfer.
Insurance Information: As per Belgian healthcare regulations, the estimated reimbursement amount has been deducted from the total. Please present this invoice and your mutual insurance card to your provider for any remaining claims. Our practice in Brussels is registered with all major Belgian mutualities.
VAT Information: Value Added Tax (VAT) is applied at the standard Belgian rate of 21% on non-reimbursed medical services and optical aids. Medical consultations covered by the national health insurance scheme may be exempt from VAT depending on specific conditions.
Follow-up: Please schedule your follow-up appointment within 6 months for continued monitoring of your ocular health. Contact our Brussels office at +32 2 555 0199 to book.
Data Protection: Your personal and medical data are processed in accordance with the Belgian Data Protection Act and the EU General Data Protection Regulation (GDPR).
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