Invoice Optometrist in United States Miami –Free Word Template Download with AI
Dr. Elena Rodriguez, O.D.
1200 Brickell Avenue, Suite 400
Miami, FL 33131, United States
Phone: (305) 555-0199 | Fax: (305) 555-0198
Email: [email protected]
FL Tax ID: 20-1234567 | NPI: 1234567890
Invoice Number: INV-2023-10-8842
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Date: October 24, 2023
Bill To:
Mr. James Anderson
4500 Collins Avenue, Apt 12B
Miami Beach, FL 33140, United States
Phone: (305) 555-0244
Email: [email protected]
Insurance: Blue Cross Blue Shield of Florida
Policy ID: BCBS-FL-99887766
Group Number: GRP-445566
Prescription Details:
Patient DOB: 05/12/1985
Exam Type: Comprehensive Dilated Eye Exam
Provider: Dr. Elena Rodriguez, O.D.
Diagnosis: ICD-10: H52.11 (Myopia), H52.5 (Presbyopia)
Refraction: OD: -2.50 -0.75 x 180 | OS: -2.75 -0.50 x 175
Add: +1.50
| # | Description of Services / Products | CPT / HCPCS Code | Qty | Unit Price | Total |
|---|---|---|---|---|---|
| 1 | Comprehensive Ophthalmological Evaluation (New Patient) including visual acuity, refraction, slit-lamp examination, and dilated fundus examination. | 92004 | 1 | $250.00 | $250.00 |
| 2 | Advanced Diagnostic Imaging: Optical Coherence Tomography (OCT) of the macula and optic nerve head for glaucoma screening. | 92134 | 1 | $150.00 | $150.00 |
| 3 | Premium Anti-Reflective Coated Eyeglass Lenses (High Index 1.67) with Blue Light Filtering technology. | V2800 | 1 | $320.00 | $320.00 |
| 4 | Designer Eyeglass Frames (Titanium Rimless Collection) - Style #TR-900. | V2788 | 1 | $285.00 | $285.00 |
| 5 | Laboratory Dispensing Fee for precision lens edging and frame adjustment. | V2020 | 1 | $45.00 | $45.00 |
| Subtotal: | $1,050.00 |
| Florida State Sales Tax (6%): | $63.00 |
| Insurance Adjustment (BCBS FL): | -$400.00 |
| Insurance Payment Applied: | -$350.00 |
| Patient Responsibility (Due): | $363.00 |
Payment Terms & Conditions:
This invoice represents the final accounting for services rendered at our Miami, Florida clinic. Payment is due within 30 days of the invoice date. Please make checks payable to "Miami Vision Specialists" or pay online via our secure patient portal. A late fee of 1.5% per month will be applied to balances remaining unpaid after the due date.
Insurance Notice: We have submitted the allowable charges to your insurance provider, Blue Cross Blue Shield of Florida. The amount listed as "Insurance Adjustment" reflects the difference between our standard fee and the contracted rate with your insurer. You are responsible for any co-pays, deductibles, or non-covered services as outlined in your policy.
Prescription Rights: In accordance with Florida Statutes and federal law, your eyeglass prescription is yours. You are free to purchase your eyewear from any licensed optician in the United States. However, purchasing directly from our Miami location ensures a seamless fitting process and immediate access to our optometrist for adjustments.
Follow-Up Care: Your next comprehensive eye exam is recommended in 12 months. Please schedule your appointment by calling our Miami office at (305) 555-0199. Regular eye exams are crucial for detecting early signs of systemic health issues such as diabetes and hypertension.
If you have any questions regarding this invoice or your eye health, please do not hesitate to contact our billing department. We are committed to providing transparent pricing and exceptional optometric care in the Miami-Dade community.
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT