Invoice Ophthalmologist in Venezuela Caracas –Free Word Template Download with AI
Specialized Ophthalmology Center
Av. Francisco de Miranda, Edificio Torre Médica, Piso 8
Chacao, Caracas, Venezuela
Tel: +58 (212) 555-0199 | Email: [email protected]
RIF: J-12345678-9
Invoice Number: INV-2023-0892
Date of Issue: October 24, 2023
Due Date: November 07, 2023
Payment Status: Pending
Bill To:
Patient Name: Juan Carlos Pérez Rodríguez
Cédula de Identidad: V-15.432.109
Address: Urbanización El Rosal, Caracas, Venezuela
Phone: +58 (412) 123-4567
Insurance Provider: Seguro Médico Nacional
Policy Number: SMN-99887766
Group Number: GRP-4455
Referring Physician: Dr. Roberto Méndez
Services Rendered
| # | Description of Ophthalmological Service | Code | Qty | Unit Price (USD) | Total (USD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Dilated Eye Examination by Senior Ophthalmologist | OPH-001 | 1 | 85.00 | 85.00 |
| 2 | Optical Coherence Tomography (OCT) - Retinal Scan | OPH-015 | 1 | 120.00 | 120.00 |
| 3 | Visual Field Test (Perimetry) - Glaucoma Screening | OPH-022 | 1 | 65.00 | 65.00 |
| 4 | Corneal Topography Mapping | OPH-030 | 1 | 90.00 | 90.00 |
| 5 | Prescription for Corrective Lenses (Bifocal) | OPH-045 | 1 | 25.00 | 25.00 |
| 6 | Consultation for Cataract Evaluation and Surgical Planning | OPH-050 | 1 | 110.00 | 110.00 |
| 7 | Anterior Segment Photography | OPH-060 | 1 | 40.00 | 40.00 |
| 8 | Follow-up Visit Post-Examination | OPH-005 | 1 | 50.00 | 50.00 |
| Subtotal: | $585.00 |
| Discount (Insurance Coverage): | -$200.00 |
| Adjustable Tax (IVA 16%): | $63.20 |
| Total Amount Due: | $448.20 |
Payment Terms and Conditions
This invoice is issued in accordance with the regulations of the Venezuelan Ministry of Health and the local tax authority (SENIAT). All amounts are quoted in United States Dollars (USD) as per current market exchange rates applicable in Caracas, Venezuela.
Payment Methods Accepted:
- Bank Transfer: Banco Mercantil, Caracas Branch. Account No: 0104-1234-5678-9012-3456. IBAN: VE0101041234567890123456.
- Cash: USD bills accepted at our reception desk in Chacao, Caracas.
- Digital Wallets: Zelle, PayPal, or local Venezuelan fintech platforms (Pago Móvil equivalent in USD).
Important Notes:
- Payment is due within 14 days from the date of this invoice.
- Late payments may incur a penalty fee of 2% per month.
- Please include the Invoice Number (INV-2023-0892) as the reference for all payments.
- This document serves as an official receipt for medical expenses and can be used for insurance reimbursement claims.
- For any discrepancies or questions regarding this invoice, please contact our billing department at [email protected] or call +58 (212) 555-0199.
Authorized by:
Dr. María Elena González
Chief Ophthalmologist
Clínica Ocular Caracas
Received by:
_________________________
Patient Signature
Date: _______________
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