Invoice Ophthalmologist in Ethiopia Addis Ababa –Free Word Template Download with AI
Specialized Ophthalmology Clinic
Bole Road, Friendship Building, 4th Floor
Addis Ababa, Ethiopia
Tel: +251 11 618 4500 | Email: [email protected]
TIN: 0012345678 | License No: ETH-OPTH-2023-089
| Invoice No: | INV-AAVC-2024-0892 |
| Date: | October 15, 2024 |
| Due Date: | October 30, 2024 |
| Payment Status: | Pending |
BILL TO:
Patient Name: Abebe Kebede
Address: Kirkos Sub-City, Woreda 05
Addis Ababa, Ethiopia
Phone: +251 911 234 567
Insurance Provider: Ethiopian Social Security Agency
Policy Number: ESSA-2024-78901
Group ID: GOV-EMP-456
Referring Physician: Dr. Selam Tadesse
| # | Description of Ophthalmological Services | Code | Qty | Unit Price (ETB) | Total (ETB) |
|---|---|---|---|---|---|
| 1 | Comprehensive Ophthalmological Examination including visual acuity testing, intraocular pressure measurement, and slit-lamp biomicroscopy performed by certified ophthalmologist. | OPH-92004 | 1 | 1,500.00 | 1,500.00 |
| 2 | Dilated Fundus Examination with retinal imaging to assess macular degeneration and diabetic retinopathy screening. | OPH-92250 | 1 | 2,200.00 | 2,200.00 |
| 3 | Anterior Segment Optical Coherence Tomography (AS-OCT) for corneal and anterior chamber analysis. | OPH-92134 | 1 | 3,500.00 | 3,500.00 |
| 4 | Prescription Eyeglasses with anti-reflective coating and UV protection lenses (single vision). | OPT-80100 | 1 | 4,800.00 | 4,800.00 |
| 5 | Preservative-free artificial tears (30ml bottle) for dry eye syndrome management. | PHM-84231 | 2 | 350.00 | 700.00 |
| 6 | Follow-up consultation with ophthalmologist for post-examination review and treatment planning. | OPH-99213 | 1 | 1,000.00 | 1,000.00 |
| Subtotal: | 13,700.00 ETB |
| Discount (Insurance Coverage): | -5,480.00 ETB |
| VAT (15%): | 1,233.00 ETB |
| GRAND TOTAL: | 9,453.00 ETB |
PAYMENT INSTRUCTIONS:
Bank Transfer: Commercial Bank of Ethiopia, Branch: Bole, Account Name: Addis Ababa Vision Care Center S.C., Account Number: 1000123456789
CBE Birr: +251 911 618 4500
Telebirr: +251 911 618 4500
Cash Payment: Accepted at clinic reception during business hours (Monday-Friday: 8:00 AM - 6:00 PM, Saturday: 8:00 AM - 2:00 PM)
Please reference Invoice Number INV-AAVC-2024-0892 with all payments.
TERMS AND CONDITIONS:
1. Payment is due within 15 days of the invoice date. Late payments may incur a 2% monthly interest charge.
2. This invoice is issued in accordance with Ethiopian tax regulations and the National Bank of Ethiopia guidelines.
3. All ophthalmological services are provided by licensed medical professionals registered with the Ethiopian Medical Association.
4. Insurance claims must be submitted within 30 days of service. Our billing department will assist with pre-authorization when required.
5. Any discrepancies in this invoice must be reported within 7 days of receipt. Please contact our billing department at [email protected].
6. This document serves as an official receipt upon payment confirmation and may be used for tax deduction purposes in Ethiopia.
7. Patient records and medical reports related to these services are maintained in compliance with Ethiopian health data protection laws.
8. Addis Ababa Vision Care Center reserves the right to adjust charges if services rendered differ from those listed, with prior patient notification.
Authorized Signature
Dr. Legesse Worku, MD
Chief Ophthalmologist
Addis Ababa Vision Care Center
Patient Acknowledgment
Signature: ___________________
Date: ___________________
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