Quotation Estimate Ophthalmologist in United States Chicago –Free Word Template Download with AI
1200 N. Michigan Avenue, Suite 450, Chicago, Illinois 60610, United States
Phone: (312) 555-0187 | Email: [email protected]
Illinois Medical License No. 240.001234 | NPI: 1093847562
Quotation EstimateQuotation Details
Quotation No.: QE-2025-04872
Date Issued: June 12, 2025
Valid Until: July 12, 2025 (30 days)
Prepared By: Dr. Margaret Chen, MD, FACS
Specialty: Comprehensive Ophthalmologist Services
Client Information
Client Name: Robert J. Whitfield
Address: 847 W. Fullerton Ave., Chicago, IL 60614
Phone: (773) 555-0234
Email: [email protected]
Insurance Provider: Blue Cross Blue Shield of Illinois
Policy No.: BCB-IL-9928471
Dear Mr. Whitfield,
Thank you for contacting Lakeview Ophthalmology Associates for a comprehensive evaluation of your ocular health needs. This Quotation Estimate has been prepared by our board-certified Ophthalmologist team to provide you with a transparent and detailed breakdown of the anticipated costs for the recommended ophthalmological services to be performed at our practice located in United States Chicago, Illinois. All pricing reflects current 2025 fee schedules and complies with Illinois state medical billing regulations.
Itemized Services and Costs| # | Service Description | CPT Code | Qty | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Dilated Eye Examination by Ophthalmologist (includes visual acuity, refraction, intraocular pressure, and retinal assessment) | 92014 | 1 | $285.00 | $285.00 |
| 2 | Optical Coherence Tomography (OCT) of the Macula and Optic Nerve | 92133 | 1 | $195.00 | $195.00 |
| 3 | Wide-Field Fundus Photography (bilateral, 45-degree fields) | 92236 | 1 | $145.00 | $145.00 |
| 4 | Anterior Segment Biometry (IOL Master 700) for Cataract Surgical Planning | 92131 | 1 | $120.00 | $120.00 |
| 5 | Corneal Topography (Pentacam HR) – Bilateral | 92020 | 1 | $110.00 | $110.00 |
| 6 | Phacoemulsification Cataract Surgery with Premium Toric IOL Implant (per eye) | 66984 | 2 | $3,450.00 | $6,900.00 |
| 7 | Post-Operative Follow-Up Visits (includes 1 week, 1 month, and 3 months post-surgery) | 99213 | 6 | $95.00 | $570.00 |
| 8 | Prescription for Post-Operative Medications (antibiotic drops, anti-inflammatory drops, lubricant) | N/A | 1 | $85.00 | $85.00 |
| 9 | Custom Bifocal Prescription Eyeglasses (frame and lenses, single vision with anti-reflective coating) | N/A | 1 | $420.00 | $420.00 |
| 10 | Annual Ophthalmologist Monitoring Visit (subsequent year, includes OCT and IOP check) | 99214 | 1 | $210.00 | $210.00 |
| Subtotal: | $9,040.00 | ||||
| Illinois State Sales Tax (6.25% on eyewear only): | $26.25 | ||||
| TOTAL ESTIMATED COST: | $9,066.25 | ||||
Based on your Blue Cross Blue Shield of Illinois policy, the following estimated insurance coverage applies to this Quotation Estimate. Please note that final reimbursement amounts are determined by your insurance carrier and may vary. Our Ophthalmologist office in United States Chicago will submit all claims electronically on your behalf.
| Category | Estimated Insurance Coverage | Estimated Patient Responsibility |
|---|---|---|
| Diagnostic Services (Items 1–5) | $720.00 | $135.00 (Deductible) |
| Surgical Services (Items 6–8) | $6,850.00 | $705.00 (Co-insurance) |
| Eyewear and Follow-Up (Items 9–10) | $150.00 | $486.25 |
1. This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. After the expiration date, pricing may be subject to revision based on updated fee schedules, insurance policy changes, or material cost fluctuations in the United States Chicago metropolitan medical market.
2. All surgical procedures will be performed by a board-certified Ophthalmologist who is a member of the American Academy of Ophthalmology (AAO) and holds active privileges at NorthShore University HealthSystem and Rush University Medical Center in Chicago, Illinois.
3. The total estimated cost of $9,066.25 is a good-faith estimate. Actual charges may vary by up to 10% depending on intraoperative findings, additional procedures necessitated by medical necessity, or changes in the patient's clinical condition. The Ophthalmologist will obtain written consent before performing any procedure not listed in this Quotation Estimate.
4. Payment is due within thirty (30) days of the date of service. We accept all major credit cards (Visa, Mastercard, American Express, Discover), HSA/FSA cards, and personal checks. A 1.5% monthly late fee will be applied to balances exceeding the payment window.
5. This practice operates in full compliance with the Health Insurance Portability and Accountability Act (HIPAA), the Illinois Personal Information Protection Act, and all applicable federal and state regulations governing medical billing and patient privacy in the United States.
6. Cancellation of scheduled surgical procedures must be communicated at least seventy-two (72) hours in advance. Cancellations within 72 hours of the scheduled procedure date will incur a $500 administrative fee.
7. This Quotation Estimate does not constitute a guarantee of medical outcomes. All surgical procedures carry inherent risks, which will be discussed in detail during the pre-operative consultation with your treating Ophthalmologist.
8. Any disputes regarding billing or services rendered should be directed to our Patient Financial Services department at (312) 555-0187, ext. 204, located at our Chicago, Illinois office.
Acceptance and AuthorizationBy signing below, the client acknowledges receipt of this Quotation Estimate, confirms understanding of the estimated costs for the recommended Ophthalmologist services, and authorizes Lakeview Ophthalmology Associates to proceed with the outlined treatment plan at our facility in United States Chicago, Illinois.
Client SignatureRobert J. Whitfield | Date: _______________ Ophthalmologist / Authorized Representative
Dr. Margaret Chen, MD, FACS | Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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