Invoice Optometrist in United States New York City –Free Word Template Download with AI
Dr. Elena Rossi, O.D., F.A.A.O.
123 West 57th Street, Suite 400
New York, NY 10019
United States
Phone: (212) 555-0199 | Fax: (212) 555-0198
Email: [email protected]
NPI: 1234567890 | NY State License: OD-123456
Invoice Number: INV-NYC-2023-8842
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Date: October 20, 2023
Bill To:
Mr. Jonathan Sterling
456 Park Avenue South
Apt 7B
New York, NY 10016
United States
Phone: (646) 555-0123
Insurance Information:
Primary Payer: Empire BlueCross BlueShield
Member ID: EBCBS-99887766
Group Number: NY-CORP-5500
Policyholder: Jonathan Sterling
Date of Birth: 05/12/1985
| # | Description of Optometric Services | CPT Code | Quantity | Amount (USD) |
|---|---|---|---|---|
| 1 |
Comprehensive Ophthalmological Evaluation Includes history taking, visual acuity testing, refraction, and assessment of ocular health. Performed by Dr. Rossi in our Manhattan clinic. |
92004 | 1 | $250.00 |
| 2 |
Dilated Fundus Examination Detailed examination of the retina and optic nerve following pharmacological dilation. Essential for detecting glaucoma and macular degeneration. |
92004 | 1 | $150.00 |
| 3 |
Optical Coherence Tomography (OCT) Non-invasive imaging test that uses light waves to take cross-section pictures of your retina, the light-sensitive tissue at the back of your eye. |
92134 | 1 | $300.00 |
| 4 |
Visual Field Test (Automated) Perimetry testing to assess peripheral vision and detect blind spots, crucial for glaucoma monitoring in New York City residents. |
92083 | 1 | $200.00 |
| 5 |
Prescription Eyewear Dispensing High-index anti-reflective lenses with blue light filtering technology. Frame selection from our premium collection. |
V2800 | 1 | $450.00 |
| 6 |
Contact Lens Fitting and Evaluation Initial fitting for toric contact lenses including follow-up assessment and care instructions. |
V2500 | 1 | $175.00 |
| Subtotal: | $1,525.00 |
| Insurance Adjustment: | -$650.00 |
| Insurance Payment: | -$400.00 |
| NY State Sales Tax (8.875%): | $46.69 |
| Patient Responsibility: | $521.69 |
Payment Terms and Conditions:
This invoice represents the total charges for optometric services rendered at Manhattan Vision Specialists, located in New York City, United States. Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly finance charge. We accept all major credit cards, HSA/FSA cards, and personal checks. For questions regarding this invoice or your eye care treatment, please contact our billing department at (212) 555-0199.
Please note that as an independent optometrist practice in New York State, we are required to collect applicable sales tax on retail optical goods including frames and contact lenses. Professional services are exempt from sales tax under NY State regulations. Insurance benefits vary by plan; please verify your coverage details with your provider.
Privacy Notice: In accordance with HIPAA regulations and New York State privacy laws, your personal health information is protected and will not be disclosed without your consent except as required by law. This invoice contains protected health information (PHI). If you have received this document in error, please notify us immediately and destroy all copies.
Disclaimer: The services described in this invoice were performed by licensed optometrists in good standing with the New York State Board of Optometry. All diagnostic procedures and treatment recommendations are based on current clinical standards of care. This invoice does not constitute a guarantee of specific visual outcomes. Patients are responsible for following prescribed treatment plans and attending recommended follow-up appointments.
Collection Policy: Accounts remaining unpaid after 60 days may be referred to a collection agency. In such cases, additional fees and interest may apply. We strive to work with patients to arrange payment plans when necessary. Please contact our office before your account becomes delinquent.
Return Policy: Prescription eyewear purchased from our practice may be returned within 14 days of purchase if there are manufacturing defects or fitting issues. Contact lenses are final sale due to health and safety regulations. All returns require original receipt and must be approved by our clinical staff.
Authorized SignatureDr. Elena Rossi, O.D.
Manhattan Vision Specialists Patient Acknowledgment
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
Create your own Word template with our GoGPT AI prompt:
GoGPT