Invoice Ophthalmologist in Spain Valencia –Free Word Template Download with AI
Specialized Ophthalmology Center
Carrer de Xàtiva, 45, 46007 Valencia, Spain
NIF: B-46123456 | Medical License: V-98765
Phone: +34 960 123 456 | Email: [email protected]
Invoice Number: INV-2023-10-045
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Service Period: October 2023
Bill To (Patient)
Mr. Alejandro Martinez Ruiz
NIF: 12345678Z
Av. del Puerto, 12, 46021 Valencia, Spain
Phone: +34 600 111 222
Email: [email protected]
Insurance / Third Party Payer
Sanitas Salud S.A.
Policy Number: SAN-99887766
Group Code: VAL-CORP-001
Reference: Pre-authorization #PRE-2023-889
| # | Description of Ophthalmological Services | Date | Qty | Unit Price (€) | Total (€) |
|---|---|---|---|---|---|
| 1 |
Comprehensive Ophthalmological Examination Includes visual acuity testing, refraction, slit-lamp biomicroscopy, and intraocular pressure measurement. Conducted by Dr. Elena Soler, Senior Ophthalmologist at Valencia Vision Institute. |
2023-10-10 | 1 | 85.00 | 85.00 |
| 2 |
Dilated Fundus Examination Detailed retinal evaluation using mydriatic agents to assess the optic nerve, macula, and peripheral retina for signs of diabetic retinopathy or glaucoma. |
2023-10-10 | 1 | 45.00 | 45.00 |
| 3 |
Optical Coherence Tomography (OCT) High-resolution cross-sectional imaging of the retina to detect early signs of macular degeneration and other retinal pathologies. |
2023-10-10 | 1 | 120.00 | 120.00 |
| 4 |
Corneal Topography Advanced mapping of the corneal surface curvature to evaluate astigmatism and suitability for refractive surgery procedures. |
2023-10-15 | 1 | 95.00 | 95.00 |
| 5 |
Prescription Eyewear Consultation Final prescription verification and consultation for progressive lenses tailored to patient's specific visual needs and occupational requirements. |
2023-10-15 | 1 | 35.00 | 35.00 |
| 6 |
Follow-up Consultation Post-treatment review and assessment of therapeutic response to prescribed ophthalmic medications. |
2023-10-22 | 1 | 55.00 | 55.00 |
| Subtotal: | 435.00 € |
| IVA (21% - Standard Rate Spain): | 91.35 € |
| Insurance Coverage (Sanitas): | -250.00 € |
| Amount Due: | 276.35 € |
Payment Instructions
Please remit payment within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge as per Spanish commercial law.
Bank Transfer Details:
Bank: Banco Santander S.A.
IBAN: ES91 0049 0001 2345 6789 0123
BIC/SWIFT: BSCHESMMXXX
Reference: INV-2023-10-045
Accepted Payment Methods: Bank Transfer, Credit Card (Visa, Mastercard), Cash (in clinic only)
Terms and Conditions
1. This invoice represents professional ophthalmological services rendered at Valencia Vision Institute, located in Valencia, Spain. All services comply with the regulations established by the General Council of Opticians and Ophthalmologists of Spain.
2. The prices listed include all professional fees for the ophthalmologist and associated diagnostic procedures. IVA (Value Added Tax) is calculated at the standard Spanish rate of 21% as applicable to private medical services not covered by the public health system.
3. Insurance reimbursements are estimates based on pre-authorization. Any discrepancies between billed amounts and actual insurance payments are the responsibility of the patient.
4. Medical records and diagnostic images (OCT, Topography) are retained for a minimum of 10 years in accordance with Spanish health data protection laws (LOPD/GDPR).
5. For any questions regarding this invoice or your ophthalmological treatment, please contact our billing department at [email protected] or call +34 960 123 456.
6. This document serves as an official receipt for tax purposes in Spain. Please retain a copy for your records.
Authorized by:
Dr. Elena Soler García
Lead Ophthalmologist
Valencia Vision Institute
Patient Acknowledgment:
I acknowledge receipt of this invoice and the services rendered.
Signature: _________________________
Date: _________________________
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