Invoice Ophthalmologist in United States Houston –Free Word Template Download with AI
1200 McKinney Street, Suite 400
Houston, Texas 77010
United States Houston
Phone: (713) 555-0199
Fax: (713) 555-0198
NPI: 1234567890 | TX MED: 000000000
INVOICE
Invoice Number: INV-2023-8842
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Service Date: October 20, 2023
Bill To (Patient)Mr. James Anderson
4500 Westheimer Road
Houston, TX 77027
United States Houston
Date of Birth: 05/12/1975
Phone: (281) 555-0123
Insurance InformationPrimary Payer: Blue Cross Blue Shield of Texas
Policy Number: BCBS-TX-99887766
Group Number: GRP-554433
Subscriber ID: JANDERSON75
Relationship: Self
Detailed Statement of Ophthalmology Services| Date | CPT Code | Description of Service | Mod | Charges | Patient Resp. |
|---|---|---|---|---|---|
| 10/20/2023 | 92004 | Comprehensive Ophthalmological Evaluation: Initial or subsequent examination and management of a patient with a specific ocular condition. This visit included a detailed history of the patient's visual complaints, a review of systemic health factors affecting ocular health, and a comprehensive external examination of the eyes and adnexa. | - | $350.00 | $75.00 |
| 10/20/2023 | 92014 | Diagnostic Procedures: Ocular ultrasound, A-scan and B-scan, performed during the consultation to assess the structural integrity of the posterior segment of the eye. This non-invasive imaging technique is standard protocol in our Houston clinic for evaluating vitreous and retinal conditions. | - | $225.00 | $45.00 |
| 10/20/2023 | 92250 | Fluorescein Angiography: Intravenous injection of fluorescein dye followed by photography of the retina. This procedure was necessary to evaluate the vascular health of the retina and detect any leakage or abnormal blood vessel growth associated with the patient's diagnosis. | - | $450.00 | $90.00 |
| 10/20/2023 | 92285 | Optical Coherence Tomography (OCT): High-resolution cross-sectional imaging of the retina. This advanced diagnostic tool allows our ophthalmologist to visualize the layers of the retina in detail, crucial for diagnosing macular degeneration and glaucoma. | - | $300.00 | $60.00 |
| 10/20/2023 | 99214 | Office Visit (Established Patient): Evaluation and management service for an established patient, requiring a detailed interval history, detailed examination, and moderate complexity medical decision making. | - | $200.00 | $40.00 |
Payment Methods: We accept cash, personal checks, Visa, MasterCard, American Express, and Discover. Online payments can be made securely through our patient portal at www.houstonvisionspecialists.com/pay.
Insurance Verification: This invoice reflects the estimated patient responsibility based on the information provided by your insurance carrier. Please note that final determination of benefits is the responsibility of the insurance company. If your insurance plan requires a referral or pre-authorization for ophthalmology services, it is the patient's responsibility to ensure these are in place prior to treatment.
Due Date: Payment is due within 30 days of the invoice date. Late payments may be subject to a 1.5% monthly finance charge.
Questions: If you have any questions regarding this invoice or the services provided by our ophthalmologist, please contact our billing department at (713) 555-0199 between 8:00 AM and 5:00 PM CST, Monday through Friday.
Location: Our clinic is conveniently located in the heart of downtown Houston, Texas, United States Houston, providing easy access for patients from across the Greater Houston area.
Authorized ByDr. Sarah Mitchell, M.D.
Board-Certified Ophthalmologist
Houston Vision Specialists
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