Invoice Optometrist in United States Houston –Free Word Template Download with AI
1234 Medical Center Blvd, Suite 500
Houston, Texas 77030, United States
Phone: (713) 555-0199 | Fax: (713) 555-0198
Email: [email protected]
TIN: 74-1234567 | Texas Optometry License: TX-98765
Invoice Number: INV-2023-10-458
Date Issued: October 24, 2023
Due Date: November 24, 2023
Payment Terms: Net 30 Days
Bill To:
Mr. James Anderson
456 Westheimer Road, Apt 12B
Houston, Texas 77027, United States
Phone: (832) 555-0123
Email: [email protected]
Insurance / Payer Info:
Vision Plan: VSP Vision Care
Member ID: VSP-99887766
Group Number: GRP-HOU-554
Subscriber: James Anderson
Date of Service: October 20, 2023
| # | Description of Services / Products | CPT / HCPCS Code | Qty | Unit Price | Total |
|---|---|---|---|---|---|
| 1 |
Comprehensive Eye Examination Includes visual acuity testing, refraction, ocular health assessment, and intraocular pressure measurement. Performed by licensed Optometrist in Houston, TX. |
92004 | 1 | $185.00 | $185.00 |
| 2 |
Dilated Fundus Examination Detailed examination of the retina and optic nerve using mydriatic agents to detect early signs of glaucoma, macular degeneration, and diabetic retinopathy. |
92250 | 1 | $120.00 | $120.00 |
| 3 |
Prescription Eyeglasses (Single Vision) High-index 1.67 lenses with anti-reflective coating and UV protection. Frame: Titanium Alloy (Model: TX-200). Dispensed at Houston Premier Optometry. |
V2800 | 1 | $450.00 | $450.00 |
| 4 |
Glaucoma Screening (OCT Scan) Optical Coherence Tomography scan to measure retinal nerve fiber layer thickness. Essential for monitoring ocular health in Houston residents over 40. |
92134 | 1 | $210.00 | $210.00 |
| 5 |
Patch Test for Contact Lens Fitting Trial fitting and evaluation of soft contact lenses for astigmatism correction. Includes follow-up consultation. |
V2500 | 1 | $95.00 | $95.00 |
| Subtotal: | $1,060.00 |
| Insurance Adjustment (VSP): | -$420.00 |
| Texas Sales Tax (8.25% on goods only): | $37.13 |
| Total Amount Due: | $677.13 |
Payment Instructions
Bank Transfer (ACH):
Bank Name: Houston Community Bank
Account Name: Houston Premier Optometry LLC
Routing Number: 111000025
Account Number: 9876543210
Check Payments: Please make checks payable to "Houston Premier Optometry" and mail to the address listed in the header.
Credit Card: Payments can be made securely online at www.houstonpremieroptometry.com/pay or by calling (713) 555-0199.
Note: Late payments may incur a 1.5% monthly interest charge as per Texas state regulations.
Terms and Conditions
1. This invoice represents services rendered by a licensed Optometrist in the state of Texas. All procedures were conducted in accordance with the Texas Optometry Practice Act.
2. Insurance benefits are subject to verification. The patient is responsible for any co-pays, deductibles, or non-covered services not paid by the insurance provider.
3. Prescription eyewear purchases include a 30-day warranty against manufacturing defects. This warranty is valid only within the United States.
4. Please retain this invoice for your personal records and tax purposes. It serves as proof of payment for medical expenses incurred in Houston, Texas.
5. If you have any questions regarding this invoice or your eye care treatment, please contact our billing department during business hours (Monday-Friday, 9:00 AM - 5:00 PM CST).
Authorized Signature (Provider)
Dr. Sarah Mitchell, O.D.
Lead Optometrist
Received By (Patient)
Date: _______________
Signature: _______________
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