Invoice Ophthalmologist in Japan Kyoto –Free Word Template Download with AI

Billed To (Patient)

Name: Tanaka Yuki

Address: 4-2-1 Sakyo-ku, Kyoto, Japan 606-8501

Phone: +81-90-1234-5678

National Health Insurance ID: NH-882910-KY

Payment Information

Bank Name: Mizuho Bank, Kyoto Main Branch

Account Type: Ordinary Account

Account Number: 1234567

Account Name: Kyoto Vision Eye Care Center

#	Description of Ophthalmological Services	Code	Quantity	Amount (JPY)
1	Comprehensive Ophthalmological Examination Initial consultation and diagnostic assessment performed by a certified Ophthalmologist in Kyoto. Includes patient history review, visual acuity testing, and preliminary ocular health evaluation.	OPH-001	1	¥ 15,000
2	Advanced Retinal Imaging (OCT) Optical Coherence Tomography scan to analyze the layers of the retina. Essential for diagnosing macular degeneration and glaucoma, a standard procedure at our Kyoto facility.	OPH-045	1	¥ 25,000
3	Intraocular Pressure Measurement Tonometry test to measure eye pressure, critical for monitoring glaucoma risk factors.	OPH-012	1	¥ 3,500
4	Prescription for Corrective Lenses Detailed refraction analysis and prescription issuance for high-index lenses tailored for astigmatism correction.	OPH-088	1	¥ 5,000
5	Specialized Consultation Fee Senior Ophthalmologist consultation fee for complex case review regarding diabetic retinopathy management.	OPH-900	1	¥ 10,000

Subtotal: ¥ 58,500 Consumable Materials Fee: ¥ 2,000 National Health Insurance Deduction (70%): - ¥ 42,350 Patient Responsibility (30%): ¥ 18,150 Consumable Surcharge (Patient Pay): ¥ 2,000 TOTAL DUE: ¥ 20,150

Terms and Conditions

1. Payment Terms: Payment is due within 30 days of the invoice date. Late payments may incur a penalty fee of 1.5% per month.

2. Insurance Information: This invoice reflects the standard 30% co-payment required under the Japanese National Health Insurance system. The remaining 70% has been billed directly to the insurance provider. Please ensure your insurance card was presented at the time of service in Kyoto.

3. Medical Records: Detailed medical records regarding this ophthalmological examination are available upon request. Please contact the clinic administration in Kyoto for copies.

4. Disputes: Any discrepancies regarding this invoice must be reported within 14 days of receipt. Please reference the Invoice Number INV-2023-10-045 in all correspondence.

5. Privacy: Your personal and medical data is handled in strict accordance with the Japanese Act on the Protection of Personal Information (APPI).

Authorized Signature

Dr. Kenji Sato, MD, PhD

Chief Ophthalmologist

Kyoto Vision & Eye Care Center

Patient Acknowledgement

Signature:

Date:

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