Invoice Occupational Therapist in United States Los Angeles –Free Word Template Download with AI
1234 Wilshire Boulevard, Suite 400
Los Angeles, CA 90017
United States
Phone: (213) 555-0199 | Email: [email protected]
NPI: 1234567890 | CA License: OT-98765
Date: October 24, 2023
Due Date: November 24, 2023
Bill To:
John Doe
5678 Sunset Blvd
Los Angeles, CA 90028
United States
Insurance: Blue Cross Blue Shield of California
Member ID: BCBS-99887766
Group Number: GRP-12345
| Date | CPT Code | Description of Occupational Therapy Services | Units | Amount (USD) |
|---|---|---|---|---|
| Oct 02, 2023 | 97110 | Therapeutic exercises for upper extremity strengthening and range of motion improvement. | 1 | $120.00 |
| Oct 05, 2023 | 97530 | Self-care management training focusing on adaptive techniques for daily living activities. | 1 | $115.00 |
| Oct 09, 2023 | 97110 | Continued therapeutic exercises targeting core stability and postural alignment. | 1 | $120.00 |
| Oct 12, 2023 | 97535 | Training in the use of assistive devices for home safety and independence. | 1 | $110.00 |
| Oct 16, 2023 | 97112 | Nerve gliding exercises and manual therapy techniques for pain reduction. | 1 | $125.00 |
| Oct 20, 2023 | 97161 | Occupational therapy evaluation and comprehensive treatment planning. | 1 | $150.00 |
Payment Instructions & Notes:
Please remit payment within 30 days of the invoice date. Payments can be made via check, credit card, or bank transfer. For online payments, please visit our secure portal at www.westsideotgroup.com/pay.
This invoice reflects services provided by a licensed Occupational Therapist in accordance with the standards of practice in the State of California and the United States. All services were rendered at our clinic located in Los Angeles, CA.
If you have any questions regarding this invoice or your treatment plan, please contact our billing department at (213) 555-0199 or email [email protected]. We are committed to ensuring transparency and clarity in all financial matters related to your care.
Thank you for choosing Westside Occupational Therapy Group for your rehabilitation needs. We are dedicated to helping you achieve your functional goals and improve your quality of life through evidence-based occupational therapy interventions.
Authorized SignatureSarah Jenkins, OTR/L
Lead Occupational Therapist Patient Signature (Acknowledgment)
__________________________
Date: ____________________ ⬇️ Download as DOCX Edit online as DOCX
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