Invoice Occupational Therapist in United States New York City –Free Word Template Download with AI
Licensed Occupational Therapy Practice
450 West 33rd Street, Suite 800
New York, NY 10001
United States
Phone: (212) 555-0198 | Fax: (212) 555-0199
Email: [email protected]
NPI: 1234567890 | NY State License: OT-98765432
Payment Due Upon Receipt
Bill To:
Mr. Jonathan A. Sterling
123 Park Avenue South, Apt 4B
New York, NY 10003
United States
Phone: (646) 555-0123
Insurance: Empire BlueCross BlueShield
Member ID: EBC-9988776655
Group Number: NY-METRO-445
| Date | Description of Occupational Therapy Services | CPT Code | Units | Rate | Amount |
|---|---|---|---|---|---|
| Oct 02 | Initial Evaluation: Comprehensive assessment of upper extremity function and ADLs in New York City home environment. | 97161 | 1 | $185.00 | $185.00 |
| Oct 05 | Therapeutic Exercise: Strengthening and range of motion exercises for shoulder rehabilitation. | 97110 | 1 | $95.00 | $95.00 |
| Oct 09 | Manual Therapy: Joint mobilization and soft tissue techniques to reduce pain and improve mobility. | 97140 | 1 | $110.00 | $110.00 |
| Oct 12 | Sensory Integration: Activities to improve sensory processing and motor planning skills. | 97530 | 1 | $105.00 | $105.00 |
| Oct 16 | ADL Training: Instruction in adaptive techniques for dressing and bathing. | 97535 | 1 | $100.00 | $100.00 |
| Oct 20 | Follow-up Evaluation: Progress assessment and modification of treatment plan. | 97162 | 1 | $145.00 | $145.00 |
Important Notes & Payment Instructions:
Payment Methods: This invoice may be paid via check, credit card (Visa, MasterCard, Amex), or bank transfer. For credit card payments, please call our billing department at (212) 555-0198. For bank transfers, please use the following details: Bank Name: Chase Manhattan Bank, Account Number: 123456789, Routing Number: 021000021.
Insurance Information: This invoice reflects services provided by a licensed Occupational Therapist in accordance with New York State regulations. Please submit this invoice to your insurance provider if you have not already done so. Our office will assist with any necessary documentation or pre-authorization requirements.
Late Payment Policy: Payments not received within 30 days of the invoice date will be subject to a late fee of 1.5% per month on the outstanding balance. Please contact us immediately if you are experiencing financial difficulties or have questions about your bill.
Privacy Notice: Your personal health information is protected under HIPAA regulations. This invoice contains protected health information and should be handled accordingly.
Authorized Signature:
Sarah Jenkins, OTR/L
Lead Occupational Therapist
Manhattan Integrated Rehabilitation
Patient Signature:
___________________________
Date: ___________________
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