Invoice Dietitian in United States San Francisco –Free Word Template Download with AI
Lead Dietitian: Elena Rodriguez, MS, RDN, LD
123 Market Street, Suite 400
San Francisco, CA 94105
United States
Phone: (415) 555-0199 | Email: [email protected]
CA Seller's Permit: #05-1234567-8901
Date Issued: October 24, 2023
Due Date: November 24, 2023
Bill To:
Client Name: James & Sarah Miller
456 Pacific Heights Blvd
San Francisco, CA 94115
United States
Insurance Provider: Blue Shield of California
Member ID: BS-99887766
Group Number: SF-GRP-2023
| # | Description of Dietitian Services | Date | CPT Code | Qty | Amount (USD) |
|---|---|---|---|---|---|
| 1 |
Initial Comprehensive Nutrition Assessment Detailed medical history review, dietary intake analysis, and metabolic evaluation conducted in our San Francisco clinic. Includes development of a personalized nutrition care plan tailored to client's specific health goals and lifestyle within the Bay Area context. |
Oct 05, 2023 | 97802 | 1 | $185.00 |
| 2 |
Nutrition Counseling Session (Individual) Follow-up consultation focusing on diabetes management strategies. Review of blood glucose logs, adjustment of macronutrient ratios, and education on label reading for local grocery options available in San Francisco markets. |
Oct 12, 2023 | 97803 | 1 | $145.00 |
| 3 |
Medical Nutrition Therapy (MNT) Plan Development Creation of a customized 4-week meal plan incorporating Mediterranean diet principles. Includes shopping lists optimized for Whole Foods and local farmers' markets in the San Francisco Bay Area, ensuring accessibility and seasonal appropriateness. |
Oct 15, 2023 | 97804 | 1 | $120.00 |
| 4 |
Nutrition Counseling Session (Telehealth) Virtual follow-up via secure HIPAA-compliant platform. Progress review, troubleshooting dietary adherence challenges, and motivational interviewing to support long-term behavior change. |
Oct 26, 2023 | 97803 | 1 | $145.00 |
| 5 |
Supplement Analysis and Recommendation Review of current vitamin and supplement regimen. Evidence-based recommendations for adjustments based on recent lab work and dietary gaps identified during assessment. |
Oct 26, 2023 | 97802 | 0.5 | $92.50 |
Important Notes & Payment Instructions:
Thank you for choosing Golden Gate Clinical Nutrition for your dietary health needs in San Francisco. As a licensed Registered Dietitian Nutritionist (RDN) in the State of California, all services provided adhere to the highest standards of clinical practice and ethical guidelines set forth by the Academy of Nutrition and Dietetics.
Payment Terms: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly finance charge. We accept payments via check made payable to "Golden Gate Clinical Nutrition," major credit cards (Visa, MasterCard, Amex), and HSA/FSA cards. For online payments, please visit our secure portal at www.ggnutrition.com/pay.
Insurance Information: This invoice reflects an estimated insurance adjustment based on your Blue Shield of California plan benefits. Please submit this invoice along with the Explanation of Benefits (EOB) to your insurance provider if required. Note that some plans may require a referral from your primary care physician for coverage of dietitian services.
Confidentiality: All patient information and health records are maintained in strict confidence in accordance with HIPAA regulations and California state privacy laws.
Questions? If you have any questions regarding this invoice or the services provided, please contact our billing department at (415) 555-0199 or email [email protected]. We are committed to ensuring a transparent and positive experience for all our clients in the San Francisco community.
Authorized Signature:Elena Rodriguez, MS, RDN, LD
Lead Dietitian, Golden Gate Clinical Nutrition Client Acknowledgment:
James & Sarah Miller
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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