Invoice Ophthalmologist in Canada Vancouver –Free Word Template Download with AI
1200 West Georgia Street, Suite 400
Vancouver, BC V6E 4R2
Canada
Phone: (604) 555-0199
Email: [email protected]
INVOICE
Invoice Number: INV-2023-8842Date Issued: October 24, 2023
Due Date: November 24, 2023
Provider ID: BC-MED-99283
Service Provider
Dr. Elena Rossi, M.D., FRCSC
Board Certified Ophthalmologist
Member of the Royal College of Physicians and Surgeons of Canada
License No: BC-OPH-44921
Bill To
Mr. James Henderson
4500 Marine Drive
West Vancouver, BC V7W 2H8
Canada
Patient ID: VH-2023-1102
Insurance: Blue Cross BC (Group #4492)
| # | Description of Ophthalmological Services | Code / Ref | Unit Price (CAD) | Total (CAD) |
|---|---|---|---|---|
| 1 |
Comprehensive Dilated Eye Examination Initial consultation and detailed assessment of ocular health. Includes history taking, visual acuity testing, slit-lamp biomicroscopy, and dilated fundus examination to evaluate retina and optic nerve health. Performed in accordance with British Columbia Medical Services Plan (MSP) guidelines. |
K010 | $150.00 | $150.00 |
| 2 |
Optical Coherence Tomography (OCT) Advanced non-invasive imaging of the retina. This diagnostic procedure provides high-resolution cross-sectional images of the macula and optic nerve head, essential for detecting early signs of glaucoma, macular degeneration, and diabetic retinopathy common in Vancouver's aging demographic. |
K025 | $220.00 | $220.00 |
| 3 |
Glaucoma Screening & Tonometry Measurement of intraocular pressure (IOP) using Goldmann applanation tonometry. Includes peripheral visual field testing (Humphrey Field Analyzer) to assess for visual field defects associated with glaucomatous damage. |
K030 | $180.00 | $180.00 |
| 4 |
Prescription for Corrective Lenses Detailed prescription for bifocal corrective lenses based on refraction results. Includes pupillary distance measurement and specific lens recommendations for digital eye strain, considering the patient's occupational requirements in the Vancouver tech sector. |
RX-01 | $50.00 | $50.00 |
| 5 |
Follow-up Consultation (Post-Exam) Review of diagnostic imaging results and discussion of treatment plan. Includes prescription for lubricating eye drops and recommendations for lifestyle modifications to manage dry eye syndrome, prevalent in the Pacific Northwest climate. |
K015 | $100.00 | $100.00 |
| Subtotal: | $700.00 |
| BC Provincial Tax (GST/HST): | $0.00 |
| Insurance Adjustment (MSP): | -$150.00 |
| Total Due (CAD): | $550.00 |
Important Notes & Payment Terms
Payment Methods: We accept Visa, Mastercard, Interac e-Transfer, and certified cheques payable to "Vancouver Vision Specialists". Please include the Invoice Number (INV-2023-8842) with all payments.
Insurance Claims: As a registered Ophthalmologist in Canada, we have submitted the eligible portion of this invoice directly to the British Columbia Medical Services Plan (MSP). The remaining balance is the patient's responsibility or may be covered by your private extended health insurance provider. Please retain this document for your records and for submission to your insurance carrier.
Privacy Policy: In compliance with the Personal Information Protection and Electronic Documents Act (PIPEDA) and British Columbia's Freedom of Information and Protection of Privacy Act (FIPPA), your medical and financial information is kept strictly confidential.
Due Date: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge. If you have any questions regarding this invoice or your eye care treatment, please contact our billing department at (604) 555-0199.
Authorized SignatureDr. Elena Rossi, M.D., FRCSC Patient Acknowledgement
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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