Invoice Optometrist in United States San Francisco –Free Word Template Download with AI
Dr. Elena Rodriguez, O.D.
123 Market Street, Suite 400
San Francisco, CA 94105
United States
Phone: (415) 555-0199
Email: [email protected]
CA Optometry License #: 12345
Invoice Number: INV-2023-10-045
Date Issued: October 24, 2023
Due Date: November 24, 2023
Payment Terms: Net 30
Bill To:
James Anderson
456 Valencia Street
San Francisco, CA 94110
United States
Phone: (415) 555-0123
Email: [email protected]
Insurance Information:
Provider: Blue Shield of California
Policy Number: BS-99887766
Group Number: GRP-554433
Subscriber ID: SUB-112233
Relationship: Self
| # | Description of Services | CPT Code | Qty | Unit Price | Total |
|---|---|---|---|---|---|
| 1 |
Comprehensive Eye Examination Includes visual acuity testing, refraction, ocular health assessment, and intraocular pressure measurement. Performed by Dr. Rodriguez at our San Francisco clinic. |
92004 | 1 | $250.00 | $250.00 |
| 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 | $150.00 | $150.00 |
| 3 |
Binocular Vision Assessment Evaluation of eye teaming, focusing, and tracking abilities. Essential for diagnosing convergence insufficiency and other binocular vision disorders common in digital users. |
92082 | 1 | $125.00 | $125.00 |
| 4 |
Prescription Eyewear - Single Vision Lenses High-index 1.67 anti-reflective coated lenses. Includes frame selection consultation and precise measurement for pupillary distance and segment height. |
V2800 | 1 | $450.00 | $450.00 |
| 5 |
Designer Eyeglass Frame Titanium semi-rimless frame (Model: SF-Modern-04). Includes adjustment and fitting services to ensure optimal comfort and alignment. |
V2000 | 1 | $325.00 | $325.00 |
| 6 |
Contact Lens Fitting and Evaluation Initial fitting for daily disposable soft contact lenses. Includes corneal topography mapping and follow-up evaluation to ensure proper fit and ocular health. |
V2520 | 1 | $175.00 | $175.00 |
| 7 |
Contact Lens Supply (30-Day Box) Daily disposable soft contact lenses (30 lenses). Prescription verified and dispensed according to California state regulations. |
V2020 | 1 | $65.00 | $65.00 |
| 8 |
Glaucoma Screening - Visual Field Test Automated perimetry to assess peripheral vision and detect potential glaucomatous field loss. Critical for patients with elevated intraocular pressure. |
92083 | 1 | $110.00 | $110.00 |
| Subtotal: | $1,650.00 |
| Insurance Adjustment (Blue Shield): | -$825.00 |
| Insurance Payment Applied: | -$620.00 |
| CA Sales Tax (8.5% on goods only): | $65.63 |
| Patient Responsibility: | $270.63 |
Important Notes & Terms:
This invoice represents services rendered by Bay Area Vision Specialists, a licensed optometry practice located in San Francisco, California, United States. All medical services are performed by Dr. Elena Rodriguez, O.D., or qualified optometric technicians under her direct supervision.
Payment Policy: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly finance charge. Please include the invoice number (INV-2023-10-045) with all payments.
Insurance: We have submitted claims to your insurance provider, Blue Shield of California. The amount shown as "Patient Responsibility" is your estimated out-of-pocket cost based on your plan benefits. Final amounts may vary slightly based on insurance adjudication.
Prescription Rights: In accordance with California law and the Federal Contact Lens Rule, your eyeglass and contact lens prescriptions are available upon request. You have the right to purchase your eyewear from any licensed retailer.
Follow-Up Care: Please schedule your next comprehensive eye examination within 12 months, or sooner if you experience any changes in vision, eye pain, or discomfort. Regular eye exams are essential for maintaining optimal ocular health.
Payment Methods Accepted:
Check: Payable to "Bay Area Vision Specialists" and mail to the address listed above.
Credit Card: Visa, MasterCard, American Express, Discover accepted over the phone at (415) 555-0199.
Online Payment: Visit our secure portal at www.bayareavision.com/pay-invoice
HSA/FSA: We accept Healthcare Savings Account and Flexible Spending Account cards.
Dr. Elena Rodriguez, O.D.
Date: _______________ Patient Acknowledgment:
I acknowledge receipt of this invoice.
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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