Quotation Estimate Ophthalmologist in Germany Berlin –Free Word Template Download with AI
Comprehensive Ophthalmologist Services
Berlin, Germany — Federal Republic of Germany
| Quotation Estimate No.: | QTE-BER-2025-04871 |
| Date of Issue: | 14 June 2025 |
| Valid Until: | 14 September 2025 (90 days) |
| Prepared By: | Dr. med. Katharina Vogel, Facharzt für Augenheilkunde (Ophthalmologist) |
| Practice Address: | Augenarztpraxis am Brandenburger Tor, Friedrichstraße 142, 10117 Berlin, Germany |
| Client / Patient: | Mr. Jonathan A. Whitfield, 28 Kurfürstendamm, 10709 Berlin, Germany |
| Insurance Reference: | TK Deutschland — Policy No. TK-88234-2025 |
This Quotation Estimate has been prepared by our Ophthalmologist practice located in Germany Berlin to provide Mr. Whitfield with a detailed, transparent, and itemised financial overview of the proposed ophthalmological examination, diagnostic procedures, and potential therapeutic interventions. As a licensed Ophthalmologist operating under the medical regulations of the State of Berlin and the Federal Republic of Germany, we are committed to full cost transparency in accordance with the German Medical Fee Schedule (Gebührenordnung für Ärzte, GOÄ) and the applicable provisions of the Social Code V (SGB V) governing statutory health insurance in Germany Berlin.
This Quotation Estimate is non-binding and serves solely as an informational document. It does not constitute a contractual obligation for either party. The final billing will be issued only after the Ophthalmologist has completed the clinical assessment and the patient has provided informed written consent for any recommended procedures.
The following services have been outlined by our Ophthalmologist team based on the preliminary consultation conducted on 10 June 2025 at our clinic in central Germany Berlin. The patient presented with progressive bilateral visual acuity reduction, intermittent photophobia, and a family history of age-related macular degeneration. The Ophthalmologist has recommended a comprehensive diagnostic workup as detailed below.
| Item No. | Description of Ophthalmologist Service | GOÄ Code | Estimated Cost (EUR) |
|---|---|---|---|
| 01 | Comprehensive Ophthalmologist consultation and medical history review (initial visit, 30 min) | GOA 01 | € 68.40 |
| 02 | Refraction and visual acuity assessment (Snellen chart, phoropter, subjective refraction) | GOA 20 | € 42.15 |
| 03 | Slit-lamp biomicroscopy of the anterior segment (bilateral, performed by Ophthalmologist) | GOA 21 | € 55.80 |
| 04 | Dilated fundus examination with indirect ophthalmoscopy (Ophthalmologist procedure) | GOA 22 | € 48.60 |
| 05 | Optical Coherence Tomography (OCT) — macular and peripapillary scan (bilateral) | GOA 23 | € 124.50 |
| 06 | Automated perimetry (Humphrey 24-2) for visual field mapping | GOA 24 | € 89.30 |
| 07 | Fluorescein angiography (FA) — intravenous dye injection and serial imaging | GOA 25 | € 156.75 |
| 08 | Intraocular pressure measurement (Goldmann applanation tonometry, bilateral) | GOA 26 | € 34.20 |
| 09 | Anterior segment OCT and corneal topography (Pentacam) | GOA 27 | € 98.40 |
| 10 | Follow-up Ophthalmologist consultation and written report (20 min, within 14 days) | GOA 02 | € 45.60 |
| 11 | Pharmacological agents: mydriatic drops (Tropicamide 1%) and lubricating eye drops | GOA 30 | € 18.90 |
| 12 | Administrative and documentation fees (medical records, insurance processing in Germany Berlin) | — | € 12.00 |
| Subtotal (before statutory health insurance reimbursement) | € 734.60 | ||
| Estimated TK Deutschland reimbursement (approx. 80%) | −€ 587.68 | ||
| Estimated Patient Co-payment (Zuzahlung) | € 146.92 | ||
3.1 Validity: This Quotation Estimate is valid for a period of ninety (90) calendar days from the date of issue. After this period, the Ophthalmologist reserves the right to revise the estimated costs due to changes in the GOÄ fee schedule, pharmaceutical pricing, or operational costs within Germany Berlin.
3.2 Insurance Coverage: The estimated reimbursement amounts are based on the current benefit catalogue of TK Deutschland. The Ophthalmologist practice in Germany Berlin will submit all claims directly to the statutory health insurance provider. The patient is responsible for the standard annual co-payment (Jahreszuzahlung) of up to €550 for medications and €550 for medical services as stipulated under §61 SGB V.
3.3 Additional Procedures: Should the Ophthalmologist identify the need for additional diagnostic or therapeutic interventions beyond those listed in this Quotation Estimate (e.g., surgical referral, intravitreal injections, or laser therapy), a supplementary Quotation Estimate will be issued prior to any such procedure. No additional costs will be incurred without the patient's explicit written consent.
3.4 Cancellation Policy: Appointments with the Ophthalmologist must be cancelled at least 48 hours in advance. Late cancellations or no-shows may result in a fee of up to €100, in accordance with the practice regulations applicable in Germany Berlin.
3.5 Data Protection: All patient data processed in connection with this Quotation Estimate and the subsequent Ophthalmologist treatment are handled in strict compliance with the European General Data Protection Regulation (GDPR) and the German Federal Data Protection Act (BDSG). Data is stored on secure servers located within the territory of Germany.
3.6 Governing Law: This Quotation Estimate and any resulting treatment agreement are governed by the civil law of the Federal Republic of Germany. Any disputes shall be subject to the exclusive jurisdiction of the competent courts in Berlin, Germany.
Note: This Quotation Estimate is provided by a licensed Ophthalmologist practice registered with the Ärztekammer Berlin (Berlin Medical Association). All services are performed in accordance with the professional standards of the German Ophthalmological Society (Deutsche Ophthalmologische Gesellschaft, DOG) and the applicable medical regulations in Germany Berlin.By signing below, the patient acknowledges receipt of this Quotation Estimate and confirms that the proposed Ophthalmologist services in Germany Berlin have been explained in understandable terms. This signature does not constitute a binding order but serves as confirmation of informed awareness.
For the Ophthalmologist Practice
Dr. med. Katharina Vogel
Facharzt für Augenheilkunde
Signature & Date: ___________________________
Patient / Client
Mr. Jonathan A. Whitfield
Signature & Date: ___________________________
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