Invoice Occupational Therapist in United States Houston –Free Word Template Download with AI
Licensed Occupational Therapy Practice
1200 Main Street, Suite 400
Houston, Texas 77002
United States
Phone: (713) 555-0199 | Email: [email protected]
TIN/EIN: 74-1234567
Invoice #: HTX-OT-2023-0892
Date Issued: October 24, 2023
Due Date: November 24, 2023
Bill To:
Mr. Jonathan Reynolds
4500 Westheimer Road, Apt 12B
Houston, Texas 77027
United States
Phone: (832) 555-0144
Email: [email protected]
| Description of Occupational Therapy Services | CPT Code | Date | Units | Rate | Amount |
|---|---|---|---|---|---|
|
Occupational Therapy Evaluation Comprehensive assessment of functional limitations, upper extremity strength, and activities of daily living (ADLs) performed at our Houston clinic. Includes history taking and goal setting. |
97161 | Oct 10, 2023 | 1 | $150.00 | $150.00 |
|
Therapeutic Exercise One-on-one session with a licensed Occupational Therapist focusing on range of motion, strengthening, and endurance exercises tailored to patient recovery. |
97110 | Oct 12, 2023 | 1 | $95.00 | $95.00 |
|
Manual Therapy Techniques Hands-on intervention by the Occupational Therapist to mobilize soft tissue and joints to improve function and reduce pain. |
97140 | Oct 12, 2023 | 1 | $90.00 | $90.00 |
|
Functional Training Training in activities of daily living (ADLs) and instrumental ADLs (IADLs) to promote independence in the home environment. |
97535 | Oct 17, 2023 | 1 | $100.00 | $100.00 |
|
Therapeutic Activity Purposeful activity used as a treatment medium to improve functional performance and cognitive skills. |
97530 | Oct 17, 2023 | 1 | $95.00 | $95.00 |
|
Occupational Therapy Re-evaluation Intermediate complexity re-evaluation to assess progress toward goals and modify the plan of care. |
97163 | Oct 20, 2023 | 1 | $120.00 | $120.00 |
Payment Instructions & Notes:
Payment Methods: We accept Visa, MasterCard, American Express, Discover, and personal checks. For electronic transfers, please contact our billing department in Houston.
Insurance: This Invoice reflects the estimated patient responsibility after insurance adjustments. Please submit this document along with your Explanation of Benefits (EOB) if you have not already done so.
Late Fees: As per our agreement, payments not received by the due date (November 24, 2023) may be subject to a late fee of 1.5% per month on the outstanding balance.
Disputes: If you have any questions regarding the services provided by our Occupational Therapist or the charges listed on this Invoice, please contact us immediately at (713) 555-0199.
Thank you: Thank you for choosing Houston Allied Health & Rehabilitation for your occupational therapy needs. We are committed to helping you regain independence and improve your quality of life.
Authorized Signature:Sarah Jenkins, OTR/L
Lead Occupational Therapist
Houston Allied Health & Rehabilitation Patient/Guarantor Signature:
__________________________
Date: ____________________ ⬇️ Download as DOCX Edit online as DOCX
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