Invoice Ophthalmologist in France Lyon –Free Word Template Download with AI
14 Rue de la République
69002 Lyon, France
Tel: +33 4 72 00 00 00
Email: [email protected]
SIRET: 123 456 789 00012
TVA Intracommunautaire: FR 12 123456789
RPPS: 10004567890
Conventionné: Secteur 1 (Tarif de Base)
INVOICE
Invoice Number: INV-2023-10-042
Date of Issue: October 24, 2023
Date of Service: October 20, 2023
Due Date: Upon Receipt
Patient InformationName: Jean-Pierre Dubois
Address: 25 Avenue Jean Jaurès, 69007 Lyon, France
Date of Birth: 15/05/1978
SS Number (Numéro de Sécurité Sociale): 1 78 05 69 001 234 56
Insurance / Mutuelle DetailsPrimary Insurer: CPAM Rhône (Assurance Maladie)
Secondary Insurer: Groupama Santé
Policy Number: MUT-987654321
Guarantee of Advance Payment: Tiers Payant Accepted
Description of Ophthalmological Services RenderedThe following invoice details the professional fees for specialized eye care services provided by Dr. Antoine Mercier at his clinic in Lyon, France. These services adhere to the French National Health Insurance (Assurance Maladie) tariff regulations and include comprehensive diagnostic assessments and therapeutic interventions.
| Ref | Description of Service | Code (Nomenclature) | Qty | Unit Price (€) | Total (€) |
|---|---|---|---|---|---|
| 01 |
Comprehensive Ophthalmological Consultation Initial examination including patient history review, visual acuity testing (Snellen chart), and preliminary assessment of ocular health. This consultation is standard for new patients in Lyon requiring a full eye check-up. |
Q401 | 1 | 25.00 | 25.00 |
| 02 |
Slit-Lamp Biomicroscopy Examination Detailed examination of the anterior segment of the eye (cornea, iris, lens) using a slit lamp microscope to detect abnormalities such as cataracts, corneal abrasions, or signs of glaucoma. |
Q402 | 1 | 18.50 | 18.50 |
| 03 |
Fundus Examination (Ophthalmoscopy) Dilated examination of the retina, optic nerve, and blood vessels to screen for diabetic retinopathy, macular degeneration, and other posterior segment pathologies. |
Q403 | 1 | 22.00 | 22.00 |
| 04 |
Applanation Tonometry Measurement of intraocular pressure (IOP) to assess the risk or presence of glaucoma. This is a critical diagnostic step in routine ophthalmology practice in France. |
Q404 | 1 | 15.00 | 15.00 |
| 05 |
Refraction Test and Prescription Update Subjective and objective refraction to determine the precise corrective lens power required for myopia, hyperopia, astigmatism, or presbyopia. Includes issuance of a prescription valid for optical shops in Lyon. |
Q405 | 1 | 20.00 | 20.00 |
| 06 |
Optical Coherence Tomography (OCT) Scan Advanced non-invasive imaging test that uses light waves to take cross-section pictures of the retina. This high-resolution imaging is essential for diagnosing macular diseases. |
Q410 | 1 | 45.00 | 45.00 |
| 07 |
Medical Certificate for Driving License Official certification of visual fitness required by the French Prefecture for the renewal of a driving license, confirming that the patient meets the legal visual acuity standards. |
Q420 | 1 | 10.00 | 10.00 |
- Payment Method: This invoice is issued under the "Tiers Payant" system. The primary reimbursement has been processed directly by CPAM (Caisse Primaire d'Assurance Maladie). The remaining balance has been covered by the patient's complementary insurance (Mutuelle). If Tiers Payant was not activated, the full amount of 186.60 € is due immediately.
- Validity: This medical invoice is valid for insurance claims for a period of 2 years from the date of service, in accordance with French health insurance regulations.
- Medical Records: A copy of this invoice and the associated medical report will be stored in the patient's electronic health record (Dossier Médical Partagé) accessible via the Ameli portal.
- Follow-up: Based on the OCT scan results, a follow-up consultation is recommended in 6 months to monitor retinal health. Please contact our Lyon clinic to schedule this appointment.
- Disputes: In case of any discrepancy regarding the codes or amounts listed, please contact the clinic administration within 30 days. All fees correspond to the official French medical nomenclature for ophthalmology.
- Legal Notice: Dr. Antoine Mercier is a registered medical practitioner in Lyon, France, authorized to perform all listed diagnostic and therapeutic procedures. This document serves as a legal proof of service for tax and insurance purposes.
Authorized Signature:
Antoine MercierDr. Antoine Mercier, Ophthalmologist
PAIÉ / Tiers PayantCPAM RHÔNE ⬇️ Download as DOCX Edit online as DOCX
Create your own Word template with our GoGPT AI prompt:
GoGPT