Invoice Ophthalmologist in United States New York City –Free Word Template Download with AI
450 Park Avenue, Suite 1200
New York, NY 10022
United States New York City
Phone: (212) 555-0199
Fax: (212) 555-0198
NPI: 1234567890 | NY State License: 1234567
INVOICE
Bill To (Patient) Mr. Jonathan A. Sterling123 West 72nd Street, Apt 4B
New York, NY 10023
United States New York City
DOB: 05/12/1978
Patient ID: PAT-998877
Insurance Information Empire Blue Cross Blue ShieldPolicy Holder: Jonathan A. Sterling
Group Number: NY-MET-554433
Member ID: EBCBS-99887766
Referral ID: REF-OPH-2023
Description of Ophthalmological Services Rendered| Code | Description of Service | Units | Charge Amount | Allowed Amount |
|---|---|---|---|---|
| 92004 | Comprehensive ophthalmological service; new patient. Includes history, examination, and diagnostic testing performed by the Ophthalmologist in New York City. | 1 | $450.00 | $320.00 |
| 92014 | Comprehensive ophthalmological service; established patient. Follow-up consultation regarding glaucoma management. | 1 | $350.00 | $250.00 |
| 92083 | Visual field test, computerized, with interpretation and report. Essential for monitoring peripheral vision loss. | 1 | $275.00 | $180.00 |
| 92133 | Optical coherence tomography (OCT), macula, with interpretation and report; each eye. High-resolution imaging of retinal layers. | 2 | $550.00 | $360.00 |
| 92250 | Anterior segment photography, single or multiple views, with interpretation and report. Documentation of corneal health. | 1 | $150.00 | $110.00 |
| 99214 | Office or other outpatient visit for the evaluation and management of an established patient; typical for complex medical decision making. | 1 | $300.00 | $210.00 |
| Total Billed Charges: | $2,075.00 |
| Total Allowed Amount: | $1,430.00 |
| Contractual Adjustment: | ($645.00) |
| Insurance Payment (Primary): | ($1,144.00) |
| Deductible Applied: | ($150.00) |
| Patient Responsibility: | $136.00 |
Please remit payment for the outstanding balance of $136.00 by the due date listed above. Payments can be made via credit card, check, or electronic transfer.
Check Payable To: Manhattan Vision Specialists
Mail To: 450 Park Avenue, Suite 1200, New York, NY 10022
Online Payment: www.manhattanvisionspecialists.com/pay-bill
Important Notes for the Patient
This Invoice represents the financial responsibility for ophthalmological services provided in accordance with the medical standards of the United States New York City. As a specialized medical practice, our Ophthalmologist has performed detailed diagnostic procedures to ensure the preservation of your vision. Please review the CPT codes listed above. If you have questions regarding the medical necessity of any procedure, please contact our billing department. Failure to pay the outstanding balance may result in the account being referred to a collection agency, which may affect your credit score.
Privacy Notice: In compliance with the Health Insurance Portability and Accountability Act (HIPAA), your medical and financial information is kept strictly confidential. This document contains protected health information (PHI). If you have received this Invoice in error, please notify the provider immediately and destroy this document.
Dispute Resolution: In the event of a billing dispute regarding services rendered by the Ophthalmologist, please submit a written request for review within 30 days of the Invoice date. All disputes will be handled in accordance with the laws of the State of New York.
Provider Attestation: The undersigned Ophthalmologist certifies that the services listed on this Invoice were personally performed or supervised by a qualified physician within the practice located in United States New York City. All charges reflect the standard fee schedule for the region and are consistent with Medicare and private insurance guidelines.
Electronic Funds Transfer (EFT): For corporate accounts or insurance providers wishing to pay via EFT, please contact our accounts receivable department for routing details. We encourage electronic payments to reduce processing time and environmental impact.
Medical Records: If you are transferring care to another Ophthalmologist, please note that a separate fee may apply for the release of medical records and diagnostic imaging data. This fee is not included in the current Invoice.
Emergency Services: This Invoice does not cover emergency room visits. It is strictly for scheduled outpatient ophthalmological care. In case of ocular emergency, please proceed to the nearest emergency department in New York City.
Thank You: We appreciate your trust in our medical expertise. Our goal is to provide the highest quality eye care in the United States New York City. Please schedule your next routine examination to maintain optimal eye health.
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