Invoice Optometrist in United States Chicago –Free Word Template Download with AI
Dr. Sarah Jenkins, O.D.
123 N. Michigan Avenue, Suite 400
Chicago, Illinois 60601
United States
Phone: (312) 555-0199 | Fax: (312) 555-0198
Email: [email protected]
State License No.: IL-OD-998877
Invoice Number: INV-2023-10-450
Date of Service: October 15, 2023
Invoice Date: October 16, 2023
Due Date: November 15, 2023
Bill To (Patient)Mr. James Anderson
456 W. Fullerton Parkway
Chicago, Illinois 60614
United States
Phone: (773) 555-0123
Date of Birth: 05/12/1985
Insurance InformationProvider: Blue Cross Blue Shield of Illinois
Policy Holder: James Anderson
Member ID: BCBS-IL-88776655
Group Number: GRP-CHI-2023
Subscriber Relation: Self
Services Rendered by Optometrist| Code | Description of Service | Quantity | Unit Price | Total |
|---|---|---|---|---|
| 92004 | Comprehensive Eye Exam: Initial or subsequent examination of the eye(s) and visual system, including medical history, ocular history, and general health assessment. Performed by licensed Optometrist in Chicago. | 1 | $250.00 | $250.00 |
| 92014 | Binocular Vision Assessment: Evaluation of eye alignment, focusing, and tracking abilities to detect vision therapy needs. | 1 | $120.00 | $120.00 |
| 92002 | Refraction: Determination of refractive error and prescription for corrective lenses. | 1 | $85.00 | $85.00 |
| V-001 | Premium Anti-Reflective Coating: Applied to prescription lenses to reduce glare from headlights and screens, essential for night driving in urban environments. | 1 | $150.00 | $150.00 |
| L-005 | High-Index Polycarbonate Lenses: Lightweight, durable lenses prescribed for high myopia correction. | 1 | $320.00 | $320.00 |
| F-002 | Designer Titanium Eyeglass Frames: Full-rim, hypoallergenic titanium frame selected during consultation. | 1 | $280.00 | $280.00 |
| 92003 | Follow-up Consultation: Post-exam review of diagnosis and treatment plan regarding dry eye syndrome. | 1 | $100.00 | $100.00 |
Payment Terms and Important Information
Payment Methods: We accept Visa, MasterCard, American Express, Discover, and personal checks drawn on United States banks. For electronic payments, please visit our secure portal at pay.windycityvision.com.
Insurance Claims: As a participating Optometrist in Chicago, Illinois, we have submitted the applicable portion of this invoice directly to your insurance provider. Please allow 10-14 business days for processing. If you have questions regarding your coverage, please contact your insurance carrier directly.
Late Fees: In accordance with Illinois state regulations and our office policy, accounts remaining unpaid after 30 days from the invoice date may be subject to a late fee of 1.5% per month on the outstanding balance.
Prescription Rights: Under the Federal Eyeglass Prescription Release Rule and Illinois state law, you have the right to receive a copy of your eyeglass prescription immediately following the refraction, regardless of whether you purchase eyewear from our practice.
Contact: For any discrepancies regarding this invoice, please contact our billing department at (312) 555-0199 or email [email protected]. Please reference Invoice Number INV-2023-10-450 in all correspondence.
Authorized Signature (Provider)Dr. Sarah Jenkins, O.D.
Windy City Vision Center Patient Acknowledgement
I acknowledge receipt of this invoice and understand my financial responsibility.
Signature: __________________________ Date: ______________ ⬇️ Download as DOCX Edit online as DOCX
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