Invoice Ophthalmologist in Brazil Rio de Janeiro –Free Word Template Download with AI
Specialist in Retina, Glaucoma, and Cataract Surgery
Av. Atlântica, 1702, Copacabana
Rio de Janeiro, RJ - CEP: 22021-001
Brazil
CNPJ: 12.345.678/0001-90
CRM-RJ: 52.100 | COREN-RJ: 12345
Email: [email protected]
Phone: +55 (21) 3222-8899
Invoice Number: INV-2023-10-045
Date of Issue: October 24, 2023
Due Date: November 07, 2023
Payment Terms: Net 14 Days
Bill To:
Patient Name: Maria Clara Silva Santos
CPF: 111.222.333-44
Address: Rua das Laranjeiras, 450, Apt 302
Laranjeiras, Rio de Janeiro, RJ - CEP: 22240-000
Brazil
Insurance Provider: Bradesco Saúde (Plan: Premium)
Policy Number: BR-9988776655
| # | Description of Ophthalmological Services | Tabela de Procedimentos (Code) | Date | Unit Price (BRL) | Total (BRL) |
|---|---|---|---|---|---|
| 1 |
Comprehensive Ophthalmological Examination Includes visual acuity testing, refraction, slit-lamp examination, and intraocular pressure measurement. Performed by Dr. Ricardo Mendes in Rio de Janeiro. |
41010.03-0 | Oct 20, 2023 | R$ 350.00 | R$ 350.00 |
| 2 |
Optical Coherence Tomography (OCT) High-resolution imaging of the retina and optic nerve head to assess macular degeneration and glaucoma risk. |
40102.04-8 | Oct 20, 2023 | R$ 450.00 | R$ 450.00 |
| 3 |
Visual Field Test (Perimetry) Automated perimetry to evaluate peripheral vision and detect glaucomatous field loss. |
40101.03-0 | Oct 20, 2023 | R$ 280.00 | R$ 280.00 |
| 4 |
Phacoemulsification with IOL Implantation Cataract surgery performed on the right eye. Includes pre-operative evaluation, surgical procedure, and standard intraocular lens implantation. |
41020.01-0 | Oct 22, 2023 | R$ 4,500.00 | R$ 4,500.00 |
| 5 |
Post-Operative Follow-up Consultation First post-surgical check-up to monitor healing and visual recovery. |
41010.03-0 | Oct 23, 2023 | R$ 250.00 | R$ 250.00 |
| 6 |
Prescription for Corrective Lenses Detailed prescription for post-operative glasses based on final refraction. |
41010.05-6 | Oct 23, 2023 | R$ 100.00 | R$ 100.00 |
| Subtotal: | R$ 5,930.00 |
| Insurance Coverage (80%): | - R$ 4,744.00 |
| Patient Responsibility (20%): | R$ 1,186.00 |
| TOTAL DUE: | R$ 1,186.00 |
Payment Instructions:
Please remit payment within 14 days of the invoice date. Late payments may incur a penalty of 2% plus interest of 1% per month, in accordance with Brazilian consumer law.
Bank Transfer (TED/DOC):
Bank: Banco do Brasil
Agency: 1234-5
Account: 98765-4
Account Holder: Dr. Ricardo Mendes Ophthalmology Ltda.
CNPJ: 12.345.678/0001-90
PIX Key: [email protected]
Please include the Invoice Number (INV-2023-10-045) as the payment reference.
Important Notes:
This invoice represents the professional fees for ophthalmological services rendered in Rio de Janeiro, Brazil. All procedures were performed in compliance with the standards set by the Brazilian Federal Council of Medicine (CFM) and the Brazilian Society of Ophthalmology (SBO).
The patient acknowledges that they have received a copy of their medical records and understand the nature of the procedures performed. Any questions regarding this invoice should be directed to our billing department.
In case of any discrepancies, please contact us within 30 days of the invoice date. After this period, the invoice will be considered accepted.
This document serves as an official receipt for tax purposes in Brazil. Please retain this invoice for your records.
Authorized Signature
Dr. Ricardo Mendes
Ophthalmologist
Patient Acknowledgment
Maria Clara Silva Santos
Date: _______________
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