Invoice Ophthalmologist in United States Chicago –Free Word Template Download with AI
Dr. Elena Rossi, M.D., F.A.C.S.
Board-Certified Ophthalmologist
340 East Superior Street, Suite 1200
Chicago, IL 60611, United States
Phone: (312) 555-0199 | Fax: (312) 555-0198
Email: [email protected]
NPI: 1234567890 | Tax ID: 36-1234567
Invoice Number: INV-CHI-2023-0892
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Period: October 20, 2023
Bill To:
Mr. James Anderson
1234 Lake Shore Drive, Apt 5B
Chicago, IL 60611, United States
Phone: (773) 555-0123
Email: [email protected]
Insurance Provider: Blue Cross Blue Shield of Illinois
Policy Number: BCBS-IL-99887766
Group Number: GRP-445566
Service Location:
Chicago Vision Specialists Clinic
340 East Superior Street, Suite 1200
Chicago, IL 60611, United States
Attending Physician: Dr. Elena Rossi, M.D.
Diagnosis Code (ICD-10): H52.11 (Myopia, right eye)
| # | Description of Ophthalmological Services | CPT Code | Qty | Unit Price | Total |
|---|---|---|---|---|---|
| 1 |
Comprehensive Ophthalmological Evaluation Includes history, visual acuity testing, refraction, slit-lamp examination, and dilated fundus examination. Performed by board-certified Ophthalmologist in Chicago, IL. |
92004 | 1 | $250.00 | $250.00 |
| 2 |
Optical Coherence Tomography (OCT) Non-invasive imaging test that uses light waves to take cross-section pictures of your retina. Essential for diagnosing macular degeneration and glaucoma. |
92134 | 1 | $185.00 | $185.00 |
| 3 |
Visual Field Test (Automated) Perimetry test to measure peripheral vision. Critical for monitoring glaucoma progression and neurological conditions affecting vision. |
92083 | 1 | $140.00 | $140.00 |
| 4 |
Corneal Topography Detailed mapping of the curvature of the cornea. Used for contact lens fitting and pre-surgical evaluation for LASIK or cataract surgery. |
92131 | 1 | $120.00 | $120.00 |
| 5 |
Prescription Eyewear Consultation Detailed fitting and prescription verification for corrective lenses. Includes consultation on lens materials and coatings suitable for the patient's lifestyle in the Chicago area. |
92348 | 1 | $75.00 | $75.00 |
| Subtotal: | $770.00 |
| Insurance Adjustment (BCBS): | -$320.00 |
| Insurance Payment Applied: | -$250.00 |
| Discount (Senior Citizen): | -$50.00 |
| Patient Responsibility: | $150.00 |
Payment Instructions & Terms
Due Date: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge.
Accepted Payment Methods:
- Check: Please make checks payable to "Chicago Vision Specialists" and mail to the address listed above.
- Credit Card: Visa, MasterCard, American Express, and Discover are accepted. Please call (312) 555-0199 to pay by phone.
- Online Payment: Secure payments can be made via our patient portal at www.chicagovisionspecialists.com/pay.
- HSA/FSA: We accept Health Savings Account and Flexible Spending Account cards.
Insurance Claims: This invoice reflects the amount remaining after insurance processing. If you have questions about your insurance coverage, please contact our billing department. We are in-network with most major insurance providers in the United States, including those covering residents of Chicago, IL.
Additional Information
This invoice represents professional services rendered by a licensed Ophthalmologist in the state of Illinois. All procedures were performed in accordance with the standards of the American Academy of Ophthalmology. The codes listed (CPT and ICD-10) are compliant with current United States medical billing regulations.
If you have any questions regarding this invoice, please contact our billing office during business hours (Monday-Friday, 8:00 AM - 5:00 PM CST). Please reference your Invoice Number (INV-CHI-2023-0892) when calling.
Thank you for choosing Chicago Vision Specialists for your eye care needs. We are committed to providing the highest quality ophthalmological care in the Chicago metropolitan area.
Authorized SignatureChicago Vision Specialists Patient Signature
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