Invoice Ophthalmologist in United States Los Angeles –Free Word Template Download with AI
Dr. Elena Rodriguez, M.D., F.A.C.S.
Board Certified Ophthalmologist
1234 Wilshire Boulevard, Suite 500
Los Angeles, CA 90017
United States
Phone: (213) 555-0199 | Fax: (213) 555-0198
NPI: 1234567890 | CA Medical License: A123456
Invoice Number: INV-2023-10-8842
Date of Service: October 15, 2023
Invoice Date: October 16, 2023
Due Date: November 15, 2023
Payment Status: Pending
Bill To (Patient)
Mr. James Anderson
456 Sunset Blvd, Apt 12B
Los Angeles, CA 90026
United States
Date of Birth: 05/12/1978
Phone: (323) 555-0144
Email: [email protected]
Insurance Information
Primary Payer: Blue Cross Blue Shield of California
Policy Holder: James Anderson
Member ID: BCB-9988776655
Group Number: GRP-CA-2023-55
Claim Number: CLM-20231015-001
| Date | CPT Code | Description of Ophthalmology Services | Modifiers | Charges | Allowable |
|---|---|---|---|---|---|
| 10/15/2023 | 92004 | Comprehensive ophthalmological service; includes slit-lamp biomicroscopy and ophthalmoscopy with interpretation and report, new patient. | $350.00 | $280.00 | |
| 10/15/2023 | 92083 | Visual field examination, computerized, with interpretation and report. | $275.00 | $220.00 | |
| 10/15/2023 | 92134 | Optical coherence tomography (OCT), macula (including optic nerve head), with interpretation and report. | $300.00 | $245.00 | |
| 10/15/2023 | 92250 | Fluorescein angiography; single or multiple views, with interpretation and report. | $450.00 | $360.00 | |
| 10/15/2023 | 99214 | Office or other outpatient visit for the evaluation and management of an established patient, which requires a detailed history and detailed examination. | 25 | $200.00 | $160.00 |
| Subtotal (Total Charges): | $1,575.00 |
| Insurance Allowable Amount: | $1,265.00 |
| Insurance Adjustment (Write-off): | ($310.00) |
| Insurance Payment (EOB Applied): | ($1,012.00) |
| Less: Patient Copay/Coinsurance: | ($50.00) |
| Patient Responsibility (Due): | $193.00 |
Important Notice Regarding Payment and Services
This Invoice represents the professional fees for ophthalmological services rendered by Dr. Elena Rodriguez at the Los Angeles Vision Institute. As a premier eye care facility located in the heart of the United States Los Angeles metropolitan area, we adhere to the highest standards of medical billing and patient care.
Payment Terms: Payment is due within 30 days of the invoice date. Please make checks payable to "Los Angeles Vision Institute" or pay online via our secure patient portal. Late payments may be subject to a 1.5% monthly finance charge.
Insurance Verification: While we have billed your insurance provider, Blue Cross Blue Shield of California, based on the information provided, the patient is ultimately responsible for any balance remaining after insurance adjudication. This includes deductibles, copayments, and non-covered services. Please review your Explanation of Benefits (EOB) carefully.
Financial Assistance: If you are experiencing financial hardship, please contact our billing department at (213) 555-0199. We offer payment plans for qualified patients residing in Los Angeles County.
Questions? If you have any questions regarding this Invoice or the specific CPT codes listed, please do not hesitate to contact our billing specialist. We are committed to transparency in all our financial interactions.
Authorized SignatureLos Angeles Vision Institute Patient Signature
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