Quotation Estimate Ophthalmologist in United States San Francisco –Free Word Template Download with AI
1200 Market Street, Suite 450, San Francisco, California 94102, United States
Phone: (415) 555-0187 | Email: [email protected]
CA Medical License No. A-2847561 | NPI: 1730482956
Quotation EstimateQuotation Details
Quotation No.: QTE-2025-SF-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: [Patient / Referring Physician Name]
Address: [Street Address], San Francisco, CA 94103
Phone: (415) 555-XXXX
Email: [[email protected]]
Insurance Provider: [Blue Shield / Kaiser / Aetna]
Policy / Member ID: [XXXXXX-XXXX]
This Quotation Estimate has been prepared by our licensed Ophthalmologist team at Golden Gate Vision & Eye Care Center, located in the heart of United States San Francisco, to provide a comprehensive and transparent breakdown of anticipated costs for the ophthalmological services described below. This document serves as a formal estimate and does not constitute a binding contract or a guarantee of final billing. Actual charges may vary based on the clinical findings during examination, the complexity of procedures performed, and applicable insurance coverage under the patient's plan administered within the State of California.
| # | Service / Procedure Description | CPT Code | Qty | Unit Price (USD) | Estimated Total (USD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Ophthalmologist Consultation & Dilated Eye Examination | 92014 | 1 | $385.00 | $385.00 |
| 2 | Optical Coherence Tomography (OCT) – Bilateral Retinal Imaging | 92134 | 2 | $145.00 | $290.00 |
| 3 | Automated Refraction & Visual Field Perimetry (Humphrey 24-2) | 92082 | 1 | $195.00 | $195.00 |
| 4 | Anterior Segment Biometry (IOL Master 700) for Cataract Surgery Planning | 92133 | 1 | $220.00 | $220.00 |
| 5 | Phacoemulsification Cataract Extraction with Multifocal IOL Implantation (Right Eye) | 66984 | 1 | $4,850.00 | $4,850.00 |
| 6 | Phacoemulsification Cataract Extraction with Multifocal IOL Implantation (Left Eye) | 66984 | 1 | $4,850.00 | $4,850.00 |
| 7 | Post-Operative Ophthalmologist Follow-Up Visits (3 visits over 6 weeks) | 99213 | 3 | $175.00 | $525.00 |
| 8 | Prescription Post-Operative Medications (Antibiotic & Anti-inflammatory drops) | — | 1 | $185.00 | $185.00 |
| 9 | Custom Bifocal / Progressive Lenses (Post-Surgical Refractive Correction) | — | 1 | $1,200.00 | $1,200.00 |
| 10 | Facility & Surgical Suite Fee (San Francisco Ambulatory Surgery Center) | — | 1 | $2,400.00 | $2,400.00 |
| Subtotal: | $15,100.00 | ||||
| Estimated Insurance Adjustment (70% coverage): | -$10,570.00 | ||||
| Estimated Patient Responsibility: | $4,530.00 | ||||
The Ophthalmologist overseeing this treatment plan, Dr. Margaret Chen, MD, FACS, is a board-certified ophthalmic surgeon with over 18 years of clinical experience in the San Francisco Bay Area. She is a Fellow of the American Academy of Ophthalmology, a member of the California Medical Board, and holds active privileges at the San Francisco Ambulatory Surgery Center and UCSF Medical Center. All procedures outlined in this Quotation Estimate will be performed in accordance with the standards established by the American Academy of Ophthalmology and the regulatory requirements of the State of California, United States.
- Validity: 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 changes in medical supply costs, facility fees, or insurance plan adjustments within the San Francisco metropolitan area.
- Insurance Verification: The estimated insurance adjustment is based on the patient's current plan benefits as verified on the date of this estimate. The Ophthalmologist's office will re-verify coverage prior to any surgical procedure. The patient is responsible for any co-pays, deductibles, or out-of-network charges not reflected in this estimate.
- Scope Changes: Should the Ophthalmologist identify additional conditions during the pre-operative examination that necessitate supplementary procedures (e.g., vitrectomy, corneal cross-linking, or retinal laser photocoagulation), a revised Quotation Estimate will be issued and must be approved in writing by the patient before any additional services are rendered.
- Payment Schedule: The patient's estimated responsibility of $4,530.00 is due as follows: 50% ($2,265.00) due at the time of surgical scheduling, and the remaining 50% ($2,265.00) due within fourteen (14) days following the final post-operative visit. Accepted payment methods include Visa, MasterCard, American Express, ACH bank transfer, and HSA/FSA cards.
- Cancellation Policy: Cancellations made more than 72 hours prior to a scheduled procedure will incur no fee. Cancellations within 72 hours will be subject to a $500.00 facility reservation fee, as is standard practice for Ophthalmologist surgical suites in United States San Francisco.
- Confidentiality: All patient information contained in and related to this Quotation Estimate is protected under the Health Insurance Portability and Accountability Act (HIPAA) and California Confidentiality of Medical Information Act (CMIA). This document shall not be disclosed to third parties without the patient's written consent.
- Governing Law: This Quotation Estimate and any resulting services shall be governed by the laws of the State of California, United States. Any disputes shall be resolved in the courts of San Francisco County, California.
By signing below, the patient (or authorized legal representative) acknowledges receipt of this Quotation Estimate, confirms understanding of the estimated costs for the Ophthalmologist services described herein, and authorizes the Golden Gate Vision & Eye Care Center to proceed with the outlined treatment plan in San Francisco, California, United States, subject to the terms and conditions stated above.
Patient / Authorized Representative Signature:
_______________________________
Name (Printed): _________________________
Date: _______________
Ophthalmologist / Provider Signature:
_______________________________
Dr. Margaret Chen, MD, FACS
Date: _______________
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