Invoice Ophthalmologist in Israel Jerusalem –Free Word Template Download with AI
Dr. David Cohen, MD - Board Certified Ophthalmologist
42 King George Street, Jerusalem 94101, Israel
Phone: +972-2-625-8800 | Fax: +972-2-625-8801
Email: [email protected]
VAT ID: 512345678 | Medical License: 12345
| Invoice Number: | INV-2024-0892 |
| Date Issued: | October 15, 2024 |
| Due Date: | November 15, 2024 |
| Payment Status: | Pending |
Billed To:
Sarah Goldstein
15 Nachlat Binyamin Street, Jerusalem 94261, Israel
ID Number: 001234567
Phone: +972-50-123-4567
Email: [email protected]
Insurance Provider: Maccabi Healthcare Services
Policy Number: MAC-789456123
Payment Instructions: Please remit payment within 30 days of invoice date. Bank transfer preferred to: Bank Hapoalim, Branch Jerusalem Center, Account: 999-888-777-666. Reference: INV-2024-0892. For questions regarding this invoice, contact our billing department during business hours (Sunday-Thursday, 8:00 AM - 4:00 PM Israel Standard Time).| Service Description | Code | Date | Quantity | Unit Price (ILS) | Total (ILS) |
|---|---|---|---|---|---|
| Comprehensive Ophthalmological Examination - Initial Consultation | OPH-001 | Oct 10, 2024 | 1 | 450.00 | 450.00 |
| Dilated Fundus Examination with Retinal Imaging | OPH-015 | Oct 10, 2024 | 1 | 320.00 | 320.00 |
| Optical Coherence Tomography (OCT) - Macula & Optic Nerve | OPH-022 | Oct 10, 2024 | 1 | 580.00 | 580.00 |
| Visual Field Testing (Perimetry) - Both Eyes | OPH-030 | Oct 10, 2024 | 1 | 275.00 | 275.00 |
| Corneal Topography Analysis | OPH-045 | Oct 10, 2024 | 1 | 390.00 | 390.00 |
| Intraocular Pressure Measurement (Tonometry) | OPH-008 | Oct 10, 2024 | 1 | 120.00 | 120.00 |
| Prescription Eyeglasses - Single Vision Lenses (Premium Anti-Reflective Coating) | OPT-100 | Oct 12, 2024 | 1 | 850.00 | 850.00 |
| Follow-up Consultation - Post-Examination Review | OPH-002 | Oct 14, 2024 | 1 | 280.00 | 280.00 |
| Subtotal: | 3,265.00 ILS |
| Insurance Coverage (Maccabi): | -1,800.00 ILS |
| Amount Due Before VAT: | 1,465.00 ILS |
| VAT (17%): | 249.05 ILS |
| TOTAL AMOUNT DUE: | 1,714.05 ILS |
Important Notes & Terms:
This invoice represents services rendered by Dr. David Cohen, a licensed ophthalmologist practicing in Jerusalem, Israel. All medical procedures and examinations were conducted in accordance with Israeli Ministry of Health regulations and international ophthalmological standards. The Jerusalem Vision Center is committed to providing exceptional eye care services to patients throughout Jerusalem and the surrounding regions of Israel.
Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge. Please include the invoice number (INV-2024-0892) with all payments. If you have any questions regarding the services provided or the charges listed, please contact our billing department at +972-2-625-8800 or email [email protected].
Insurance claims have been processed directly with Maccabi Healthcare Services. The amount shown as insurance coverage reflects the approved reimbursement. Any remaining balance is the patient's responsibility. Please note that VAT (Value Added Tax) of 17% is applied in accordance with Israeli tax law. This invoice serves as an official receipt for tax and insurance purposes.
For medical emergencies or urgent eye care needs in Jerusalem, please contact our emergency line at +972-2-625-8899. Regular office hours are Sunday through Thursday, 8:00 AM to 4:00 PM. Saturday appointments are available by special arrangement only.
VAT Registration Number: 512345678 | Issued in Jerusalem, Israel | This document is valid for accounting and tax purposes under Israeli law.
Authorized Signature
Dr. David Cohen, MD
Chief Ophthalmologist
Patient Acknowledgment
Sarah Goldstein
Date: _______________
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT