Invoice Occupational Therapist in United States San Francisco –Free Word Template Download with AI
1234 Market Street, Suite 500
San Francisco, CA 94103
United States
Phone: (415) 555-0199
Email: [email protected]
NPI: 1234567890 | CA License: OT-98765
Invoice #: INV-2023-10-042
Date: October 24, 2023
Due Date: November 24, 2023
PO Number: SF-HEALTH-992
BILL TO:
Golden Gate Health Systems
Attn: Accounts Payable Department
555 Geary Boulevard
San Francisco, CA 94102
United States
RE: PATIENT SERVICES
Patient Name: John Doe
DOB: 05/12/1965
Policy ID: HMO-SF-882910
Diagnosis: C79.51 (Secondary malignant neoplasm of brain)
Referring Physician: Dr. Sarah Chen, MD
| Date | CPT Code | Description of Occupational Therapy Services | Units | Rate | Amount |
|---|---|---|---|---|---|
| 10/02/2023 | 97110 | Therapeutic exercises to improve upper extremity strength and coordination following neurological event. Performed by licensed Occupational Therapist. | 1 | $120.00 | $120.00 |
| 10/02/2023 | 97530 | Self-care management training (ADLs). Focus on dressing and grooming techniques adapted for limited mobility. Conducted in clinical setting in San Francisco. | 1 | $115.00 | $115.00 |
| 10/09/2023 | 97110 | Therapeutic exercises focusing on fine motor skills and hand dexterity. Utilization of specialized equipment to enhance functional independence. | 1 | $120.00 | $120.00 |
| 10/09/2023 | 97535 | Training in activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Simulation of home environment tasks. | 1 | $110.00 | $110.00 |
| 10/16/2023 | 97112 | Nervous muscle re-education. Techniques to improve range of motion, coordination, and strength of affected limbs. Supervised by Occupational Therapist. | 1 | $125.00 | $125.00 |
| 10/16/2023 | 97530 | Self-care/home management training. Education on energy conservation techniques and safety modifications for the patient's residence in San Francisco. | 1 | $115.00 | $115.00 |
| 10/23/2023 | 97110 | Therapeutic exercises. Continued progression of upper body strengthening and balance training to prevent falls and improve stability. | 1 | $120.00 | $120.00 |
| 10/23/2023 | 97168 | Occupational therapy evaluation. Comprehensive assessment of patient's functional status, cognitive abilities, and environmental barriers. High complexity. | 1 | $180.00 | $180.00 |
Payment Terms and Important Information
Payment Method: Please remit payment via check payable to "Bay Area Occupational Therapy Group" or via electronic funds transfer (EFT) details provided upon request. Checks should be mailed to the address listed in the header.
Insurance Billing: This Invoice is submitted for reimbursement regarding services rendered by a licensed Occupational Therapist in accordance with the patient's insurance policy. All CPT codes listed above are compliant with current medical coding standards utilized in the United States. Please ensure that the remittance advice is sent to our billing department within 30 days of receipt.
Service Location: All services detailed in this document were performed at our clinic located in San Francisco, California. As per California state regulations and federal guidelines, all therapists providing these services are fully licensed and certified to practice Occupational Therapy within the state.
Late Payments: Invoices not paid by the due date may be subject to a late fee of 1.5% per month on the outstanding balance. Please contact us immediately if there are any discrepancies with this Invoice or if you anticipate a delay in payment.
Privacy Notice: In compliance with HIPAA regulations, this document contains Protected Health Information (PHI). It is intended solely for the use of the individual or entity to whom it is addressed. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or taking of action in reliance on the contents of this information is strictly prohibited.
Authorized Signature:
Jane Smith, OTR/L
Lead Occupational Therapist
Bay Area Occupational Therapy Group
Date Signed:
October 24, 2023
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