Invoice Optometrist in United States Los Angeles –Free Word Template Download with AI
Dr. Elena Rodriguez, O.D.
1234 Wilshire Boulevard, Suite 500
Los Angeles, California 90017
United States
Phone: (213) 555-0199
Email: [email protected]
CA Optometry License #: 12345
Invoice Number: INV-2023-10-8842
Date Issued: October 24, 2023
Due Date: November 24, 2023
Payment Status: Pending
Bill ToMr. James Anderson
789 Sunset Boulevard, Apt 4B
Los Angeles, California 90028
United States
Phone: (323) 555-0144
Email: [email protected]
Insurance Provider: Blue Shield of California
Policy Number: BS-CA-99887766
Group Number: GRP-554433
Service DetailsThe following invoice details the professional optometry services rendered at our Los Angeles clinic. These charges cover comprehensive eye examinations, diagnostic testing, and vision correction consultations provided in accordance with the standards of the California Board of Optometry.
| # | Description of Service | CPT Code | Qty | Unit Price | Total |
|---|---|---|---|---|---|
| 1 | Comprehensive Eye Examination (Adult). Includes history, visual acuity, refraction, and ocular health assessment. | 92004 | 1 | $250.00 | $250.00 |
| 2 | Dilated Fundus Examination. Detailed inspection of the retina and optic nerve using mydriatic agents. | 92250 | 1 | $150.00 | $150.00 |
| 3 | Optical Coherence Tomography (OCT). Advanced imaging of the retinal layers to detect early signs of macular degeneration or glaucoma. | 92134 | 1 | $200.00 | $200.00 |
| 4 | Visual Field Test (Automated). Perimetry testing to assess peripheral vision and detect neurological or glaucomatous defects. | 92083 | 1 | $175.00 | $175.00 |
| 5 | Contact Lens Fitting and Evaluation. Includes trial lens selection, corneal topography mapping, and follow-up assessment. | 92371 | 1 | $125.00 | $125.00 |
| 6 | Pediatric Vision Screening. Brief assessment for minor dependent (Age 6). | 92002 | 1 | $100.00 | $100.00 |
1. Payment Terms: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge as permitted under California law.
2. Insurance Claims: Los Angeles Vision Care will submit claims to your primary insurance provider. You are responsible for any deductibles, copayments, or non-covered services. Please verify your benefits prior to service.
3. Optometry Services: All examinations are performed by licensed optometrists in the State of California. Our clinic adheres to strict hygiene and safety protocols.
4. Disputes: If you have any questions regarding this invoice or the services rendered, please contact our billing department at (213) 555-0199 within 15 days.
5. Privacy: Your medical information is protected under HIPAA regulations. This invoice contains protected health information (PHI).
Authorized Signature:Dr. Elena Rodriguez, O.D.
Date: October 24, 2023 Patient Acknowledgement:
__________________________
Date: ____________________ ⬇️ Download as DOCX Edit online as DOCX
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