Pour un usage commercial, créatif et éducatif légitime uniquement. Toute utilisation frauduleuse est interdite. Consultez nos Conditions d'utilisation
Usage légitime uniquement. Toute utilisation frauduleuse est interdite.
Consultez nos Conditions.
Consultez nos Conditions.
Générateur gratuit Visionworks Receipt
This receipt is issued by Visionworks Doctors of Optometry and identifies Store #523 at 5509 Urbana Pike, Frederick, Maryland 21704. The header contains the Visionworks name, store address, telephone number, website information, sales receipt reference, and transaction date and time. The receipt documents an optical purchase involving eyeglass frames, right and left prescription lenses, and a premium non-glare option, together with a MetLife Choice Standard third-party plan adjustment. The financial section records the merchandise and service amounts, a $172.16 plan-related discount, subtotal and total information, and payment of $333.97 by Visa. The lower section contains third-party billing information and an authorization statement covering insurance benefits, unpaid balances, and vision-care services.
VISIONWORKS #523
DOCTORS OF OPTOMETRY
5509 URBANA PIKE
FREDERICK, MD 21704
301-682-0660
Please visit us at
www.visionworks.com
or find us on
Facebook
SALES RECEIPT 5.9
NT
00523-111933
01/15/2020 16:50:16
LINDA PFLUG
5835 PECKING STONE ST
NEW MARKET,MD 21774
H (985) 502-1227
W ( ) EXT.
DOCTOR: RUBY ARTHUR
3RD PARTY PLAN:
METLIFE CHOICE STAND
PAIR #1 DUE:
01/29/2020
1 1312564 WM 6105
(BK/G) N 99.95
1 1111110 RIGHT LENS
N 240.00
1 1111110 LEFT LENS
N 240.00
1 8001299 PREMIUM
NON-GLARE N .00
1 9010 METLIFE CHOICE
STAN N -172.16
PAYMENT 333.97 THIS
SALE 579.95
VISA 333.97 061140
DISCOUNTS
AMOUNT SAVED 172.16
SUB TOTAL 407.79
TOTAL 407.79
OLD BAL .00
333.97
PAYMENT
THIS BAL 407.79
AMT TENDERED .00
NEW BAL 407.79
CHANGE DUE .00
BALANCE DUE 407.79
3rd PARTY PLAN:
METLIFE CHOICE
STANDARD
GRP #: TO BE
BILLED: $73.82
AUTHORIZATION OF
PAYMENT AND PATIENT
RELEASE I authorize
the direct pay-
ment of
medical/vision
benefits for
all services
rendered. I accept
financial
responsibility for
any
unpaid balances not
covered by my
Vision Care Program
for services
rendered to me, my
spouse, and/or my
dependents. I
authorize the release
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1. Choisissez parmi plus de 100 modèles
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2. Ajoutez vos informations
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3. Exportez-le pour l'utiliser
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