Quotation Estimate Ophthalmologist in France Marseille –Free Word Template Download with AI
12 Boulevard du Littoral, 13007 Marseille, France
Tel: +33 (0)4 91 23 45 67 | Email: [email protected]
SIRET: 842 567 891 00012 | RPPS: 10101234567
Quotation EstimateQuotation Details
Reference No.: QTE-2025-04871
Date of Issue: 15 June 2025
Valid Until: 15 September 2025
Currency: EUR (€)
Client Information
Name: Mr. Jean-Luc Moreau
Address: 45 Rue Sainte, 13006 Marseille, France
Phone: +33 (0)6 12 34 56 78
Email: [email protected]
Insurance: CPAM + Mutuelle Harmonie (N° 2025-88431)
Dear Mr. Moreau,
Thank you for consulting our Ophthalmologist at the Clinique Ophtalmologique de Marseille. Following your comprehensive eye examination conducted on 10 June 2025, we are pleased to present this formal Quotation Estimate outlining the recommended ophthalmic procedures, associated costs, and expected reimbursement through your health insurance coverage. This document has been prepared in accordance with the French national healthcare pricing guidelines (Nomenclature des Actes Médicaux) applicable in France Marseille and the broader Provence-Alpes-Côte d'Azur region.
Based on the clinical assessment performed by Dr. Sophie Lefebvre, MD, Ophthalmologist, the following interventions are recommended to address the diagnosed bilateral cataract (stage 3) and moderate myopic astigmatism. All procedures will be carried out at our facility in France Marseille, utilizing state-of-the-art surgical equipment and adhering to the strict hygiene and safety protocols mandated by the French Agency for Healthcare Products and Safety (ANSM).
| Ref | Description of Service | CCAM Code | Unit Price (€) | Quantity | Total (€) |
|---|---|---|---|---|---|
| 01 | Initial Ophthalmologist consultation and comprehensive diagnostic workup (visual acuity, tonometry, OCT, fundus photography, biometry) | 21001200 | 110.00 | 1 | 110.00 |
| 02 | Pre-operative assessment and anaesthesia consultation (general anaesthesia for bilateral procedure) | 21001400 | 95.00 | 1 | 95.00 |
| 03 | Phacoemulsification cataract surgery with implantation of a premium multifocal intraocular lens (IOL) – Right Eye | 21001600 | 1,850.00 | 1 | 1,850.00 |
| 04 | Phacoemulsification cataract surgery with implantation of a premium multifocal intraocular lens (IOL) – Left Eye | 21001600 | 1,850.00 | 1 | 1,850.00 |
| 05 | Premium multifocal IOL (AcrySof IQ Vivity) – Right Eye | 21001800 | 620.00 | 1 | 620.00 |
| 06 | Premium multifocal IOL (AcrySof IQ Vivity) – Left Eye | 21001800 | 620.00 | 1 | 620.00 |
| 07 | Post-operative follow-up consultations (3 visits at 1 week, 1 month, and 3 months) | 21002000 | 70.00 | 3 | 210.00 |
| 08 | Prescription and dispensing of post-operative ophthalmic medications (antibiotic drops, anti-inflammatory drops, lubricant drops – 6-week supply) | 21002200 | 145.00 | 1 | 145.00 |
| 09 | Corneal topography and wavefront analysis for residual astigmatism correction planning | 21002400 | 85.00 | 1 | 85.00 |
| 10 | Custom prescription eyeglasses (progressive lenses, anti-reflective coating) – post-surgical refractive correction | 21002600 | 380.00 | 1 | 380.00 |
| TOTAL ESTIMATED COST | € 6,965.00 | ||||
As a patient registered in the France Marseille healthcare district, your base coverage through the Caisse Primaire d'Assurance Maladie (CPAM) and your supplementary Mutuelle Harmonie plan will apply to the items listed above. The following is an indicative breakdown of the expected reimbursement:
| Category | CPAM Base (€) | Mutuelle Harmonie (€) | Out-of-Pocket (€) |
|---|---|---|---|
| Surgical procedures & consultations | 1,240.00 | 890.00 | 1,025.00 |
| Premium IOLs (bilateral) | 0.00 | 480.00 | 760.00 |
| Medications & diagnostics | 198.00 | 112.00 | 120.00 |
| Prescription eyewear | 100.00 | 180.00 | 100.00 |
| TOTAL | 1,538.00 | 1,662.00 | 2,005.00 |
Note: The estimated out-of-pocket amount of €2,005.00 represents the patient's residual financial responsibility after all applicable reimbursements. Actual figures may vary slightly depending on the final coding of procedures and any updates to the French national tariff schedule.
- Validity: This Quotation Estimate is valid for a period of ninety (90) days from the date of issue. After this period, pricing may be subject to revision in line with updated French healthcare tariffs.
- Payment Schedule: A deposit of 30% (€2,089.50) is required to confirm the surgical booking. The remaining balance is due within thirty (30) days following the completion of all post-operative consultations.
- Payment Methods: We accept bank transfer (virement), credit/debit card (Visa, Mastercard, CB), and direct insurance settlement (tiers payant) for CPAM-covered items. Payment plans may be arranged upon request.
- Scheduling: The bilateral cataract surgery is tentatively scheduled for the week of 4 August 2025. The exact date will be confirmed by our Ophthalmologist team after the pre-operative anaesthesia clearance is obtained.
- Medical Clearance: The patient must provide a general practitioner's medical certificate confirming fitness for general anaesthesia no later than 14 days prior to the scheduled procedure.
- Cancellation Policy: Cancellation more than 14 days before the scheduled surgery incurs no fee. Cancellation within 14 days is subject to a 50% fee on the deposit. No refund is issued for cancellations within 72 hours of the procedure.
- Warranty: The premium IOLs carry a manufacturer's warranty of ten (10) years against optical defects. Post-operative complications directly attributable to the surgical technique are covered by our Ophthalmologist team for a period of twelve (12) months.
- Regulatory Compliance: All services described in this Quotation Estimate are performed in full compliance with the regulations of the French Ministry of Health, the Haute Autorité de Santé (HAS), and the local ARS Provence-Alpes-Côte d'Azur. Our facility in France Marseille holds a valid authorization for ophthalmic surgical procedures (N° ADE-13-2019-0442).
- Confidentiality: All medical data and financial information contained in this document are protected under the French Data Protection Act (Loi Informatique et Libertés) and the EU General Data Protection Regulation (GDPR).
By signing below, the patient acknowledges receipt of this Quotation Estimate, confirms understanding of the recommended ophthalmic procedures, and authorizes the Ophthalmologist team at Clinique Ophtalmologique de Marseille to proceed with the scheduled interventions in France Marseille under the terms and conditions outlined above.
Patient Signature
Name: Jean-Luc Moreau
Date: _________________________
Signature: _________________________
Ophthalmologist / Clinic Representative
Name: Dr. Sophie Lefebvre, MD
Date: _________________________
Signature & Stamp: _________________________
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