Invoice Ophthalmologist in Colombia Medellín –Free Word Template Download with AI
Ophthalmology & Optometry Center
Carrera 43A # 10 - 35, El Poblado
Medellín, Antioquia, Colombia
NIT: 900.123.456-7
Phone: +57 (4) 444-5555
Email: [email protected]
Invoice Number: INV-2023-8942
Date of Issue: October 24, 2023
Due Date: November 07, 2023
Service Date: October 20, 2023
Bill To (Patient)
Name: Juan Carlos Pérez Rodríguez
ID (Cédula): 1.098.765.432
Address: Calle 73 Sur # 45 - 12, Laureles
City: Medellín, Colombia
Email: [email protected]
Insurance / Third Party Payer
Provider: Sura Salud
Policy Number: POL-9988776655
Authorization Code: AUT-2023-5544
Plan Type: Premium Ophthalmology
| # | Description of Ophthalmological Services | Code (CUPS) | Qty | Unit Price (COP) | Total (COP) |
|---|---|---|---|---|---|
| 1 |
Comprehensive Ophthalmological Consultation Detailed examination of visual acuity, intraocular pressure measurement, and slit-lamp biomicroscopy performed by a certified specialist in Medellín. |
0100001 | 1 | $250,000 | $250,000 |
| 2 |
Dilated Fundus Examination Pharmacological dilation of pupils to assess the retina, optic nerve, and macula for signs of diabetic retinopathy or glaucoma. |
0100045 | 1 | $180,000 | $180,000 |
| 3 |
Optical Coherence Tomography (OCT) Advanced non-invasive imaging test that uses light waves to take cross-section pictures of the retina. Essential for diagnosing macular degeneration. |
0100112 | 1 | $450,000 | $450,000 |
| 4 |
Corneal Topography Computerized mapping of the curvature of the front surface of the eye. Required for pre-surgical evaluation and contact lens fitting. |
0100115 | 1 | $320,000 | $320,000 |
| 5 |
Prescription for Corrective Lenses Analysis and prescription for bifocal lenses based on the patient's refractive error assessment conducted in our clinic. |
0100005 | 1 | $100,000 | $100,000 |
Terms and Conditions & Payment Information
1. Payment Methods: Payment can be made via bank transfer to Bancolombia (Account #123-456789-00), credit card (Visa/Mastercard), or cash at our reception in Medellín. Please include the Invoice Number as the reference for transfers.
2. Tax Compliance: This invoice is issued in accordance with the regulations of the DIAN (Dirección de Impuestos y Aduanas Nacionales) of Colombia. The VAT (IVA) rate applied is 19%, standard for medical services not covered by the subsidized regime.
3. Insurance Claims: If you are paying out-of-pocket and seeking reimbursement from your EPS (Entidad Promotora de Salud) or Complementary Insurance, please retain this original invoice and the detailed medical report. Our billing department can assist with the electronic submission of claims to major providers in Antioquia.
4. Validity: This invoice is valid for 30 days from the date of issue. Late payments may incur a monthly interest rate of 1.5% as per Colombian commercial law.
5. Medical Disclaimer: The services listed above were performed by licensed ophthalmologists. This document serves as a financial record and does not replace the clinical medical report, which is available upon request.
Authorized Signature
Dr. María Fernanda Gómez
Lead Ophthalmologist
License No. 12345678
Received By (Patient)
__________________________
Date: ____________________
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