Invoice Ophthalmologist in United States San Francisco –Free Word Template Download with AI
Dr. Elena Rostova, M.D., F.A.C.S.
Board-Certified Ophthalmologist
1234 Market Street, Suite 400
San Francisco, CA 94103
United States
Phone: (415) 555-0199 | Fax: (415) 555-0198
Email: [email protected]
Official Statement of Account
Bill To:Mr. James Anderson
567 Valencia Street
San Francisco, CA 94110
United States
Phone: (415) 555-0821
| Code | Description of Ophthalmological Services | Qty | Unit Price | Total |
|---|---|---|---|---|
| 92004 | Comprehensive Ophthalmological Evaluation: Initial examination of the eye and adnexa in San Francisco clinic. Includes detailed history, visual acuity testing, refraction, and assessment of ocular health. | 1 | $350.00 | $350.00 |
| 92014 | Diagnostic Imaging (OCT): Optical Coherence Tomography of the retina. High-resolution cross-sectional imaging used to diagnose macular degeneration and glaucoma. | 1 | $275.00 | $275.00 |
| 92003 | Visual Field Test: Automated perimetry to assess peripheral vision. Essential for monitoring glaucoma progression in patients residing in the Bay Area. | 1 | $180.00 | $180.00 |
| 92002 | Corneal Topography: Detailed mapping of the corneal surface curvature. Required for contact lens fitting and pre-surgical evaluation. | 1 | $220.00 | $220.00 |
| 99214 | Office Visit (Established Patient): Consultation regarding post-operative care and medication management following cataract surgery. | 1 | $200.00 | $200.00 |
Payment Instructions
Please remit payment for the outstanding balance of $200.00 by the due date listed above. Payments can be made via credit card, check, or bank transfer. If paying by check, please make it payable to "Bay Area Vision Specialists" and mail to the San Francisco address listed in the header.
For online payments, please visit our secure patient portal at portal.bayareavision.com and reference Invoice Number INV-SF-2023-8842.
Terms and Conditions
1. Accuracy of Information: The patient is responsible for providing accurate insurance and personal information. Errors may result in delayed processing or additional charges.
2. Insurance Verification: While we strive to verify benefits prior to service, the patient is ultimately responsible for any co-pays, deductibles, or non-covered services as determined by their insurance carrier.
3. Late Payments: Accounts remaining unpaid 30 days past the due date may be subject to a late fee of 1.5% per month or may be referred to a collection agency.
4. Disputes: If you believe there is an error on this invoice, please contact our billing department in San Francisco within 15 days of the invoice date.
5. Privacy: In accordance with HIPAA regulations, your medical and billing information is kept strictly confidential.
6. Jurisdiction: This invoice and any related disputes are governed by the laws of the State of California.
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