Invoice Ophthalmologist in Ivory Coast Abidjan –Free Word Template Download with AI
12 Boulevard de la République
Cocody, Abidjan
Ivory Coast
Phone: +225 27 22 44 55 66
Email: [email protected]
NINEA: CI-2023-OPHTH-887766
INVOICE
Invoice Number: INV-2024-00892
Date of Issue: November 15, 2024
Due Date: December 15, 2024
Payment Terms: Net 30 Days
Currency: West African CFA Franc (XOF)
Billed To:
Patient Name: Jean-Pierre Kouassi
Address: 45 Rue des Jardins, Marcory, Abidjan, Ivory Coast
Phone: +225 07 88 99 00 11
Email: [email protected]
Insurance Provider: Mutuelle Santé Côte d'Ivoire
Policy Number: MSI-2024-554433
Group ID: GS-ABJ-7788
Services Rendered by Ophthalmologist
The following ophthalmological services were provided at our clinic in Abidjan, Ivory Coast, in accordance with the national standards for eye care and the professional guidelines of the Ivorian Medical Association. All procedures were performed by licensed ophthalmologists specializing in comprehensive eye care, refractive surgery, and ocular disease management.
| # | Description of Service | Date | Qty | Unit Price (XOF) | Total (XOF) |
|---|---|---|---|---|---|
| 1 | Comprehensive Ophthalmological Examination including visual acuity test, intraocular pressure measurement, slit-lamp examination, and dilated fundus examination performed by Dr. Amina Diallo, Ophthalmologist. | Nov 10, 2024 | 1 | 45,000 | 45,000 |
| 2 | Optical Coherence Tomography (OCT) Scan for retinal imaging and macular assessment, conducted at our Abidjan facility using state-of-the-art diagnostic equipment. | Nov 10, 2024 | 1 | 75,000 | 75,000 |
| 3 | Prescription for corrective lenses (bifocal) including detailed refraction analysis and lens parameter specification by the attending ophthalmologist. | Nov 10, 2024 | 1 | 15,000 | 15,000 |
| 4 | Follow-up consultation for glaucoma monitoring including visual field testing and optic nerve assessment, in compliance with Ivorian healthcare protocols. | Nov 12, 2024 | 1 | 35,000 | 35,000 |
| 5 | Prescription medication: Timolol maleate eye drops 0.5% (30ml) for intraocular pressure management, dispensed at our clinic pharmacy in Abidjan. | Nov 12, 2024 | 2 | 8,500 | 17,000 |
| 6 | Administrative fee for insurance claim processing and documentation submission to Mutuelle Santé Côte d'Ivoire, including translation of medical records if required. | Nov 15, 2024 | 1 | 10,000 | 10,000 |
Important Notes and Payment Instructions:
- This invoice is issued in accordance with the tax regulations of the Ivory Coast and must be retained for your records and insurance purposes.
- Payment is due within 30 days of the invoice date. Late payments may incur a penalty of 2% per month on the outstanding balance.
- Payments can be made via bank transfer to our account at Ecobank Côte d'Ivoire, Branch Cocody, Account Number: 0012345678901, IBAN: CI92 0012 3456 7890 1234 5678 90.
- Mobile money payments are accepted via Orange Money (07 88 99 00 11) and MTN Mobile Money (05 88 99 00 11) for amounts up to 200,000 XOF.
- Cash payments are accepted at our clinic reception in Abidjan during business hours (Monday to Friday, 8:00 AM - 5:00 PM; Saturday, 8:00 AM - 12:00 PM).
- Please reference the invoice number (INV-2024-00892) on all payments to ensure proper allocation.
- This invoice reflects services provided by licensed ophthalmologists registered with the Ivorian Medical Council. All procedures adhere to international standards of ophthalmic care.
- For questions regarding this invoice or your ophthalmological treatment, please contact our billing department at +225 27 22 44 55 66 or email [email protected].
- Insurance claims have been submitted on your behalf. Any discrepancies between this invoice and your insurance statement should be reported within 15 days.
- Abidjan Vision Care Center is committed to providing high-quality eye care services to patients throughout the Ivory Coast. Thank you for trusting our ophthalmologists with your vision health.
Authorized Signature
Dr. Amina Diallo
Lead Ophthalmologist
Abidjan Vision Care Center
Patient Acknowledgment
_________________________
Date: _________________
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