Invoice Occupational Therapist in United States Miami –Free Word Template Download with AI

Bill To:

Mr. Jonathan Sterling

4500 Collins Avenue, Unit 12B

Miami Beach, FL 33140, United States

Insurance Provider: Blue Cross Blue Shield of Florida

Policy Number: BCBS-FL-99887766

Group Number: GRP-MIA-4455

Description of Services	CPT Code	Date	Units	Amount (USD)
Initial Evaluation - Occupational Therapy Comprehensive assessment of functional limitations, cognitive status, and environmental barriers for a client residing in Miami. Includes history taking, standardized testing, and development of a personalized treatment plan tailored to the patient's specific needs within the United States healthcare framework.	97161	Oct 10, 2023	1	$185.00
Occupational Therapy - One-on-One Treatment Direct therapeutic intervention focusing on fine motor skills, sensory integration, and activities of daily living (ADLs). Session conducted at the Miami Wellness clinic. The Occupational Therapist provided manual therapy and adaptive strategies to improve patient independence.	97535	Oct 12, 2023	1	$120.00
Occupational Therapy - One-on-One Treatment Continued rehabilitation focusing on upper extremity strengthening and coordination. Utilization of therapeutic equipment to enhance range of motion. Documentation of progress notes compliant with Florida state regulations.	97535	Oct 17, 2023	1	$120.00
Therapeutic Exercise Program Supervised exercise program designed by the Occupational Therapist to improve joint mobility and muscle strength. Specific exercises targeted to assist the patient in returning to work duties in the Miami metropolitan area.	97110	Oct 19, 2023	1	$95.00
Home Safety Assessment Consultation Virtual consultation regarding home modifications to ensure safety and accessibility. The Occupational Therapist reviewed the patient's living environment in Miami to recommend ergonomic adjustments and fall prevention strategies.	97530	Oct 21, 2023	1	$150.00
Occupational Therapy - One-on-One Treatment Focus on cognitive rehabilitation and memory strategies. The session included role-playing scenarios relevant to the patient's daily life in the United States, ensuring cultural competency and practical application of skills.	97535	Oct 24, 2023	1	$120.00

Subtotal: $790.00 Tax (Florida State Tax 6%): $47.40 Insurance Adjustment (Est.): -$250.00 Total Due: $587.40

Terms and Conditions

This Invoice represents the professional fees for Occupational Therapy services rendered by Miami Wellness Occupational Therapy. All services were provided in accordance with the standards of practice for Occupational Therapists in the United States. Payment is due within 30 days of the invoice date. Late payments may be subject to a 1.5% monthly interest charge.

Please reference the Invoice Number (INV-2023-10-884) on all payments. Checks should be made payable to "Miami Wellness Occupational Therapy" and mailed to the address listed in the header. Electronic payments are accepted via our secure patient portal.

Insurance Information: This invoice has been submitted to your primary insurance provider. The "Insurance Adjustment" reflects the estimated portion covered by your policy. You are responsible for any co-pays, deductibles, or non-covered services as outlined in your insurance plan. If you have questions regarding your coverage, please contact your insurance provider directly.

Privacy Notice: In compliance with HIPAA regulations, your personal health information is kept strictly confidential. This invoice contains protected health information (PHI) and should be handled securely.

Thank you for choosing our Occupational Therapist services in Miami. We are committed to helping you achieve your functional goals and improve your quality of life.

Authorized Signature:
Sarah Jenkins, OTR/L
Lead Occupational Therapist
Miami Wellness Occupational Therapy Patient Acknowledgement:
__________________________
Signature
Date: ____________________ ⬇️ Download as DOCX Edit online as DOCX

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