Invoice Dietitian in United States Houston –Free Word Template Download with AI
Licensed Clinical Dietitian Services
1234 Medical Center Blvd, Suite 500
Houston, TX 77030, United States
Phone: (713) 555-0198 | Email: [email protected]
TIN/EIN: 74-1234567
Invoice #: INV-2023-10-045
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Period: October 1, 2023 - October 31, 2023
BILL TO:
Client Name: Sarah J. Thompson
Address: 5678 Westheimer Road, Apt 12B
Houston, TX 77057, United States
Phone: (281) 555-0142
Email: [email protected]
INSURANCE / PAYMENT INFO:
Provider: Blue Cross Blue Shield of Texas
Policy #: BCBS-TX-987654321
Group #: GRP-HOU-45678
PCP: Dr. Michael Rodriguez, MD
Referral #: REF-2023-8899
| # | Description of Dietitian Services | CPT Code | Qty | Rate | Amount |
|---|---|---|---|---|---|
| 1 |
Initial Comprehensive Nutrition Assessment Detailed medical history review, dietary intake analysis, and metabolic evaluation conducted at our Houston clinic. Includes development of personalized nutrition care plan aligned with current clinical guidelines. |
97802 | 1 | $185.00 | $185.00 |
| 2 |
Nutrition Counseling Session (Follow-up) One-on-one consultation focusing on diabetes management and weight optimization strategies. Includes progress monitoring, adjustment of meal plans, and behavioral modification techniques. |
97803 | 3 | $125.00 | $375.00 |
| 3 |
Medical Nutrition Therapy (MNT) for Chronic Condition Specialized therapeutic diet planning for hypertension and cardiovascular health. Includes education on sodium restriction, heart-healthy fats, and portion control specific to Houston-area dietary preferences. |
97804 | 2 | $150.00 | $300.00 |
| 4 |
Customized Meal Planning Service Development of a 4-week personalized meal plan with grocery lists, recipe suggestions, and dining-out guides tailored to local Houston restaurants and markets. |
97805 | 1 | $95.00 | $95.00 |
| 5 |
Nutritional Supplement Consultation Review and recommendation of dietary supplements based on laboratory results and individual health goals. Includes interaction check with current medications. |
97806 | 1 | $75.00 | $75.00 |
| 6 |
Virtual Nutrition Coaching Session Remote telehealth consultation via secure video platform for ongoing support and accountability. Includes real-time Q&A and plan adjustments. |
97807 | 2 | $110.00 | $220.00 |
| Subtotal: | $1,250.00 |
| Texas State Sales Tax (Exempt - Medical Services): | $0.00 |
| Insurance Adjustment (BCBS of TX): | -$450.00 |
| Patient Copay / Deductible: | $150.00 |
| TOTAL DUE: | $950.00 |
PAYMENT INSTRUCTIONS:
Due Date: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly finance charge.
Accepted Payment Methods:
- Credit/Debit Card (Visa, MasterCard, American Express, Discover)
- Bank Transfer / ACH
- Check (Payable to: Houston Elite Nutrition)
Online Payment: Visit www.houstoneleitenutrition.com/pay and enter Invoice # INV-2023-10-045
Mail Payments To:
Houston Elite Nutrition
Attn: Billing Department
1234 Medical Center Blvd, Suite 500
Houston, TX 77030, United States
TERMS AND CONDITIONS:
1. All services provided by our licensed dietitian are rendered in accordance with the standards set by the Academy of Nutrition and Dietetics and comply with Texas state regulations.
2. Insurance claims are submitted on behalf of the patient. However, the patient remains ultimately responsible for any balances not covered by their insurance provider.
3. Please verify your benefits with your insurance company prior to services. Pre-authorization may be required for certain nutrition therapy services.
4. If you have any questions regarding this invoice or your account, please contact our billing department at (713) 555-0198 or email [email protected].
5. All nutritional advice and meal plans are for informational and therapeutic purposes and should complement, not replace, medical treatment prescribed by your physician.
6. Houston Elite Nutrition is committed to protecting your privacy. All personal health information is handled in compliance with HIPAA regulations.
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT