Invoice Occupational Therapist in United States Chicago –Free Word Template Download with AI
Occupational Therapy Services
123 Michigan Avenue, Suite 400
Chicago, IL 60601
United States
Phone: (312) 555-0198
Email: [email protected]
Tax ID: 36-XXXXXXX
Invoice Number: INV-2023-10-045
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Period: October 1, 2023 - October 20, 2023
Bill To:
Mr. Robert J. Anderson
456 Lake Shore Drive, Apt 12B
Chicago, IL 60611
United States
Phone: (773) 555-0123
Email: [email protected]
Insurance / Payer Information:
Blue Cross Blue Shield of Illinois
Policy Number: BCBS-IL-99887766
Group Number: GRP-CHI-5544
Referring Physician: Dr. Sarah Jenkins, MD
Diagnosis Code: M25.561 (Pain in right knee)
| # | Description of Occupational Therapy Services | Date of Service | CPT Code | Qty | Rate | Amount |
|---|---|---|---|---|---|---|
| 1 |
Initial Evaluation - Occupational Therapy Comprehensive assessment of functional limitations, upper extremity strength, and activities of daily living (ADLs) performed at our Chicago clinic. Includes history taking, physical examination, and development of a personalized treatment plan tailored to patient needs in the United States healthcare context. |
Oct 02, 2023 | 97161 | 1 | $180.00 | $180.00 |
| 2 |
Therapeutic Exercise - Occupational Therapy Supervised exercises designed to improve range of motion, strength, and endurance. Focus on upper extremity rehabilitation and ergonomic training for workplace adaptation. Conducted by a licensed Occupational Therapist in Chicago, IL. |
Oct 05, 2023 | 97110 | 1 | $120.00 | $120.00 |
| 3 |
Manual Therapy Techniques Hands-on treatment to mobilize joints and soft tissues to improve function and reduce pain. Includes joint mobilization and soft tissue massage techniques specific to occupational therapy standards in the United States. |
Oct 09, 2023 | 97140 | 1 | $130.00 | $130.00 |
| 4 |
ADL Training (Activities of Daily Living) Instruction and therapeutic activities to improve performance in self-care tasks such as dressing, bathing, and grooming. Adaptation strategies provided for home environment in Chicago residential settings. |
Oct 12, 2023 | 97535 | 1 | $125.00 | $125.00 |
| 5 |
Work Hardening / Ergonomic Consultation Simulation of work tasks to prepare patient for return to employment. Includes ergonomic assessment and recommendations for workstation setup compliant with United States occupational safety standards. |
Oct 16, 2023 | 97545 | 1 | $140.00 | $140.00 |
| 6 |
Follow-up Evaluation - Occupational Therapy Re-assessment of progress towards goals, modification of treatment plan, and coordination of care with referring physician. Documented according to Illinois state regulations for occupational therapy practice. |
Oct 20, 2023 | 97163 | 1 | $150.00 | $150.00 |
| Subtotal: | $845.00 |
| Insurance Adjustment (BCBS): | -$253.50 |
| Insurance Payment Applied: | -$422.50 |
| Patient Responsibility (Co-pay/Deductible): | $169.00 |
| TOTAL DUE: | $169.00 |
Payment Instructions
Please make checks payable to Chicago Wellness & Rehabilitation and mail to the address listed above. For electronic payments, please use the following details:
Bank Name: Chase Bank, Chicago Branch
Account Name: Chicago Wellness & Rehabilitation LLC
Routing Number: 071000013
Account Number: XXXX-XXXX-5678
Online payments can also be made securely at www.chicagowellnessrehab.com/pay using your Invoice Number.
Terms and Conditions
1. Payment is due within 30 days of the invoice date. Late payments may be subject to a 1.5% monthly finance charge.
2. All services provided by our licensed Occupational Therapists are subject to verification of insurance benefits prior to treatment. Patient is responsible for any non-covered services or deductibles not met.
3. This Invoice reflects services rendered in accordance with the standards of practice for Occupational Therapy in the State of Illinois and the United States.
4. Please retain this document for your tax records. Services provided may be tax-deductible as medical expenses under United States federal tax law.
5. For questions regarding this Invoice or your treatment plan, please contact our billing department at (312) 555-0198 or email [email protected].
6. Chicago Wellness & Rehabilitation is committed to providing high-quality, patient-centered occupational therapy services to help individuals regain independence and improve their quality of life in the Chicago metropolitan area and beyond.
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