Quotation Estimate Ophthalmologist in United States Miami –Free Word Template Download with AI
Comprehensive Ophthalmologist Services — Miami, Florida, United States
Document No. QE-2025-04871 Provider:Dr. Elena Vasquez, MD, FACS
Board-Certified Ophthalmologist
Miami Vision & Eye Institute
3200 Biscayne Boulevard, Suite 410
Miami, FL 33137, United States
Tel: (305) 555-0192
Email: [email protected] Quotation Details:
Date Issued: June 12, 2025
Valid Until: July 12, 2025
Prepared For: Mr. Jonathan R. Whitfield
1487 Coral Way, Apt 2B
Miami, FL 33145, United States
Patient ID: MV-2025-00893
This Quotation Estimate has been prepared by the undersigned Ophthalmologist at Miami Vision & Eye Institute to provide Mr. Jonathan R. Whitfield with a detailed, itemized financial projection for the recommended ophthalmic care and surgical procedures to be performed in Miami, Florida, United States. This document serves as a formal Quotation Estimate and does not constitute a binding contract or a guarantee of medical outcomes. All pricing reflects current 2025 fee schedules for an Ophthalmologist operating within the Miami metropolitan area and is subject to the terms outlined in Section 6 of this Quotation Estimate.
Following a comprehensive diagnostic evaluation conducted on June 5, 2025, the treating Ophthalmologist has recommended the following course of treatment. Each line item below represents a component of the overall Quotation Estimate for ophthalmic care in Miami, United States:
| # | Service / Procedure Description | CPT Code | Quantity | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Dilated Eye Examination by Ophthalmologist (initial consultation, visual acuity testing, intraocular pressure measurement, retinal assessment) | 92014 | 1 | $385.00 | $385.00 |
| 2 | Optical Coherence Tomography (OCT) — Macular & Retinal Nerve Fiber Layer Analysis (both eyes) | 92134 | 2 | $195.00 | $390.00 |
| 3 | Anterior Segment & Posterior Segment Biomicroscopy with Gonioscopy | 92010 | 1 | $125.00 | $125.00 |
| 4 | Phacoemulsification Cataract Surgery with Premium Toric Intraocular Lens Implantation (Right Eye) | 66984 | 1 | $4,850.00 | $4,850.00 |
| 5 | Phacoemulsification Cataract Surgery with Premium Toric Intraocular Lens Implantation (Left Eye) | 66984 | 1 | $4,850.00 | $4,850.00 |
| 6 | Pre-operative Anesthesia Consultation & Topical Anesthetic Administration | 00180 | 2 | $210.00 | $420.00 |
| 7 | Post-operative Ophthalmologist Follow-up Visits (Week 1, Week 4, Month 3) — Miami, FL | 99213 | 3 | $175.00 | $525.00 |
| 8 | Prescription Post-operative Medications (Antibiotic & Anti-inflammatory Eye Drops, 30-day supply) | N/A | 1 | $95.00 | $95.00 |
| 9 | Surgical Facility Fee — Miami Ambulatory Surgery Center (per eye) | N/A | 2 | $1,200.00 | $2,400.00 |
| 10 | Custom Prescription Bifocal Contact Lenses (Post-surgical, both eyes) | N/A | 1 | $340.00 | $340.00 |
| Subtotal — All Ophthalmologist Services | $14,380.00 |
| Applicable Florida State Sales Tax (7.0% on applicable items) | $1,006.60 |
| Insurance Pre-authorization Adjustment (Est. 60% coverage — subject to carrier verification) | ($8,628.00) |
| Estimated Patient Responsibility — Final Quotation Estimate Amount | $6,758.60 |
Note: The insurance adjustment figure is an estimate based on the patient's current UnitedHealthcare PPO plan. The final Quotation Estimate amount payable by the patient may vary depending on the Ophthalmologist's in-network status, deductible status, and any pre-authorization conditions set forth by the insurance carrier. Miami Vision & Eye Institute will provide a final itemized statement upon completion of all services.
The Ophthalmologist providing all services outlined in this Quotation Estimate is Dr. Elena Vasquez, MD, FACS, who holds board certification through the American Board of Ophthalmology and is a Fellow of the American Academy of Ophthalmology. Dr. Vasquez has completed a three-year ophthalmic residency at the University of Miami Miller School of Medicine and a one-year subspecialty fellowship in refractive and cataract surgery. She is licensed to practice ophthalmology in the State of Florida, United States, under Medical License No. ME48291, and maintains active malpractice insurance coverage through the Miami Ophthalmic Medical Group. All surgical procedures will be performed in a Joint Commission-accredited ambulatory surgical facility located in downtown Miami, ensuring the highest standards of patient safety and clinical excellence.
This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. The patient is requested to provide a deposit of 25% of the estimated patient responsibility amount ($1,689.65) at the time of surgical scheduling to secure the Ophthalmologist's operating room time in Miami. The remaining balance is due within thirty (30) days of the final post-operative visit. Payment may be made via personal check, major credit card (Visa, Mastercard, American Express), Health Savings Account (HSA), Flexible Spending Account (FSA), or direct insurance billing. A 1.5% monthly late fee will be applied to any outstanding balance exceeding the thirty-day payment window.
- This Quotation Estimate is a good-faith financial projection and does not guarantee the final cost of ophthalmic care. Actual charges may differ due to unforeseen intraoperative findings, additional procedures necessitated by the Ophthalmologist's clinical judgment, or changes in insurance coverage.
- All services will be rendered in compliance with the Florida Medical Practice Act, the United States Federal Health Insurance Portability and Accountability Act (HIPAA), and the standards of the American Academy of Ophthalmology.
- The patient acknowledges that ophthalmic surgery, while generally safe, carries inherent risks including but not limited to infection, bleeding, retinal detachment, and incomplete visual correction. A separate informed consent document will be executed prior to any surgical procedure.
- This Quotation Estimate does not constitute a medical diagnosis or a guarantee of specific visual outcomes. The Ophthalmologist will exercise independent clinical judgment throughout the course of treatment in Miami, United States.
- Any cancellation of scheduled surgical procedures by the patient within fourteen (14) days of the scheduled date will result in forfeiture of the 25% deposit. Cancellations by the Ophthalmologist or the surgical facility due to medical necessity will result in a full refund of all deposits.
- This Quotation Estimate is governed by the laws of the State of Florida, United States. Any disputes arising from this document shall be subject to the exclusive jurisdiction of the state and federal courts located in Miami-Dade County, Florida.
By signing below, the patient acknowledges receipt of this Quotation Estimate for Ophthalmologist services in Miami, United States, and authorizes the Ophthalmologist and Miami Vision & Eye Institute to proceed with the recommended diagnostic and surgical plan as described herein. The patient further authorizes the Ophthalmologist to submit claims to the patient's insurance carrier on their behalf.
Patient SignatureMr. Jonathan R. Whitfield
Date: ______________________ Ophthalmologist / Authorized Representative
Dr. Elena Vasquez, MD, FACS
Miami Vision & Eye Institute
Date: ______________________ ⬇️ Download as DOCX Edit online as DOCX
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