Invoice Ophthalmologist in Canada Toronto –Free Word Template Download with AI
Toronto Vision Excellence Clinic
100 King Street West, Suite 2400
Toronto, Ontario, Canada Toronto M5X 1C9
Phone: (416) 555-0199 | Fax: (416) 555-0198
Email: [email protected]
College of Physicians and Surgeons of Ontario (CPSO) Reg. #12345
GST/HST Account: 123456789RT0001
Official Medical Billing Statement
Bill To: Mr. James Robertson45 Maple Leaf Avenue
Toronto, Ontario, Canada Toronto M4E 2S1
Patient ID: TR-998877
OHIP Number: 1234 5678 9012
| # | Description of Ophthalmological Services | Fee Code | Unit Price (CAD) | Total Amount (CAD) |
|---|---|---|---|---|
| 1 |
Comprehensive Dilated Eye Examination Detailed assessment of ocular health including visual acuity testing, refraction, slit-lamp biomicroscopy, and dilated fundus examination to evaluate retinal integrity and optic nerve health. Performed by Dr. Vance at our Toronto clinic. |
011.01 | $150.00 | $150.00 |
| 2 |
Optical Coherence Tomography (OCT) Scan Advanced non-invasive imaging of the retina and optic nerve head. This diagnostic procedure is essential for detecting early signs of macular degeneration, glaucoma, and diabetic retinopathy. |
015.02 | $225.00 | $225.00 |
| 3 |
Glaucoma Screening & Visual Field Test Perimetry testing to map peripheral vision and assess intraocular pressure (IOP). Critical for monitoring glaucoma progression in patients residing in the Greater Toronto Area. |
014.05 | $175.00 | $175.00 |
| 4 |
Prescription Eyewear Consultation Professional consultation for corrective lenses based on examination results. Includes analysis of lens options suitable for the patient's lifestyle and visual needs. |
012.00 | $75.00 | $75.00 |
| 5 |
Administrative & Record Keeping Fee Processing of medical records, insurance claims submission to private providers, and maintenance of patient health information in compliance with Ontario privacy laws. |
ADM-01 | $25.00 | $25.00 |
| Subtotal: | $650.00 |
| OHIP Coverage (Applicable Services): | -$350.00 |
| Balance Due (Private Pay): | $300.00 |
| HST (13% on Private Pay): | $39.00 |
| TOTAL DUE: | $339.00 CAD |
Important Notes & Payment Terms
1. Payment Policy: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge. Please make cheques payable to "Toronto Vision Excellence Clinic" or use the E-Transfer details provided below.
2. Insurance Claims: While many basic ophthalmological services are covered by the Ontario Health Insurance Plan (OHIP), advanced diagnostic imaging (such as OCT scans), certain glaucoma tests, and private consultations are not fully covered. This invoice reflects the portion of services billed directly to the patient or their private insurance provider. Please submit this invoice to your extended health benefits plan for reimbursement.
3. Medical Disclaimer: This invoice is for billing purposes only and does not constitute a medical diagnosis or treatment plan. For medical inquiries regarding your eye health, please contact our office directly. Dr. Vance and her team are dedicated to providing the highest standard of ophthalmological care in Canada Toronto.
4. Privacy: Your personal health information is protected under the Personal Health Information Protection Act (PHIPA) of Ontario. We ensure strict confidentiality in all our billing and administrative processes.
5. Contact: If you have any questions regarding this invoice, please contact our billing department at (416) 555-0199 or email [email protected]. We are here to assist you.
Authorized By: Dr. Elena Vance, MD, FRCSCSenior Ophthalmologist Patient Acknowledgement: Signature / Date ⬇️ Download as DOCX Edit online as DOCX
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