Invoice Ophthalmologist in United States Miami –Free Word Template Download with AI
1200 Brickell Avenue, Suite 400
Miami, FL 33131
United States
Phone: (305) 555-0199
Fax: (305) 555-0198
Email: [email protected]
NPI: 1234567890 | FL Medical License: ME12345678
Tax ID (EIN): 59-1234567
INVOICE
Bill To (Patient)Mr. Alejandro Rodriguez
4500 SW 8th Street, Apt 3B
Miami, FL 33134
United States
Phone: (786) 555-0123
DOB: 05/12/1978
Primary InsuranceBlue Cross Blue Shield of Florida
Policy Number: BCBF-99887766
Group Number: GRP-MIA-555
Subscriber ID: SUB-112233
Relationship: Self
Services Rendered by OphthalmologistThe following invoice details the professional fees for ophthalmological services provided in Miami, Florida. These charges reflect the standard rates for specialized eye care, diagnostic imaging, and surgical procedures performed by board-certified ophthalmologists at our facility.
| Date | CPT Code | Description of Ophthalmological Service | Units | Charge | Amount |
|---|---|---|---|---|---|
| 10/15/2023 | 92004 | Comprehensive Ophthalmological Evaluation. Includes history, examination, and diagnosis of refractive errors and ocular health assessment. | 1 | $350.00 | $350.00 |
| 10/15/2023 | 92134 | Optical Coherence Tomography (OCT) with interpretation. Detailed imaging of the retina and optic nerve head to assess macular health. | 1 | $275.00 | $275.00 |
| 10/15/2023 | 92083 | Visual Field Test (Perimetry). Automated threshold perimetry to evaluate peripheral vision and detect glaucomatous defects. | 1 | $225.00 | $225.00 |
| 10/15/2023 | 92250 | Fluorescein Angiography. Diagnostic imaging of blood flow in the retina and choroid using fluorescent dye. | 1 | $450.00 | $450.00 |
| 10/15/2023 | 99214 | Office Visit for Established Patient. Intermediate level evaluation and management of chronic ocular conditions. | 1 | $185.00 | $185.00 |
| Subtotal (Gross Charges): | $1,485.00 |
| Insurance Adjustment (Contractual): | ($650.00) |
| Insurance Payment Applied: | ($450.00) |
| Florida State Sales Tax (Exempt - Medical): | $0.00 |
| Patient Responsibility (Due): | $385.00 |
Payment Methods: We accept all major credit cards (Visa, MasterCard, American Express), checks payable to "Miami Vision Specialists," and direct bank transfers.
Online Payment: You may pay this invoice securely online at www.miamivisionspecialists.com/pay using your Invoice Number.
Check Payments: Please mail checks to the address listed in the header of this invoice in Miami, FL.
Insurance Claims: This invoice represents the balance remaining after primary insurance adjudication. If you have secondary insurance, please submit a copy of this invoice to your provider.
Late Fees: In accordance with Florida state regulations and our office policy, accounts unpaid after 60 days may be subject to a late fee of 1.5% per month or may be referred to a collection agency.
Questions? If you have any questions regarding these charges or the services provided by our ophthalmologist, please contact our billing department at (305) 555-0199 between 8:00 AM and 5:00 PM EST.
Authorized By Dr. Elena Vasquez, MDBoard Certified Ophthalmologist Patient Acknowledgement Patient Signature
Date ⬇️ Download as DOCX Edit online as DOCX
Create your own Word template with our GoGPT AI prompt:
GoGPT