Invoice Physiotherapist in United States Chicago –Free Word Template Download with AI
123 Michigan Avenue, Suite 400
Chicago, IL 60601
United States
Phone: (312) 555-0199
Email: [email protected]
Tax ID: 36-XXXXXXX
Invoice Number: INV-CHI-2023-0892
Date Issued: October 24, 2023
Due Date: November 24, 2023
Payment Terms: Net 30
Bill To:
Johnathan Doe
456 Lake Shore Drive, Apt 12B
Chicago, IL 60611
United States
Phone: (773) 555-0144
Email: [email protected]
Insurance Provider: Blue Cross Blue Shield of Illinois
Policy Number: BCBS-IL-99887766
Group Number: GRP-445566
Service Details:
Referring Physician: Dr. Sarah Jenkins, MD
Diagnosis Code (ICD-10): M54.5 (Low back pain)
Treatment Plan ID: TP-2023-445
Session Dates: Oct 10, 2023 - Oct 20, 2023
Location of Service: Chicago Elite Physiotherapy Clinic
City: Chicago
State: Illinois
Country: United States
| # | Description of Physiotherapy Services | CPT Code | Qty | Unit Price (USD) | Total (USD) |
|---|---|---|---|---|---|
| 1 |
Initial Evaluation and Treatment Planning Comprehensive assessment of musculoskeletal condition, range of motion testing, strength evaluation, and development of personalized rehabilitation protocol. Conducted by licensed Physiotherapist in Chicago. |
97161 | 1 | $150.00 | $150.00 |
| 2 |
Therapeutic Exercise Program Supervised exercise sessions focusing on core stabilization, flexibility, and strengthening exercises tailored to low back pain recovery. Includes instruction on home exercise program. |
97110 | 6 | $85.00 | $510.00 |
| 3 |
Manual Therapy Techniques Hands-on treatment including joint mobilization, soft tissue massage, and myofascial release to improve mobility and reduce pain. Performed by certified Physiotherapist. |
97140 | 4 | $95.00 | $380.00 |
| 4 |
Electrical Stimulation Therapy Application of electrical current to muscles for pain management and muscle re-education. Used as adjunct therapy in rehabilitation process. |
97014 | 3 | $60.00 | $180.00 |
| 5 |
Ultrasound Therapy Therapeutic ultrasound application to promote tissue healing, reduce inflammation, and increase blood flow to affected areas. |
97035 | 2 | $55.00 | $110.00 |
| 6 |
Patient Education and Ergonomic Consultation Instruction on proper body mechanics, posture correction, and workplace ergonomics to prevent future injury. Includes written materials. |
97530 | 1 | $75.00 | $75.00 |
| 7 |
Progress Evaluation and Treatment Modification Mid-treatment assessment to evaluate progress, adjust treatment plan, and determine continued need for physiotherapy services. |
97162 | 1 | $120.00 | $120.00 |
| Subtotal: | $1,525.00 |
| Insurance Adjustment (BCBS): | -$625.00 |
| Insurance Payment Applied: | -$750.00 |
| Patient Copay: | $50.00 |
| Patient Responsibility (Due): | $150.00 |
Payment Instructions
Amount Due: $150.00 USD
Due Date: November 24, 2023
Please make checks payable to Chicago Elite Physiotherapy and mail to:
123 Michigan Avenue, Suite 400, Chicago, IL 60601, United States
For electronic payments, please contact our billing department at (312) 555-0199 or email [email protected] with your invoice number.
We accept Visa, MasterCard, American Express, and Discover.
Terms and Conditions
1. This Invoice represents charges for physiotherapy services rendered by licensed professionals at Chicago Elite Physiotherapy, located in Chicago, Illinois, United States.
2. Payment is due within 30 days of the invoice date. Late payments may be subject to a 1.5% monthly finance charge.
3. Insurance adjustments reflect negotiated rates between Chicago Elite Physiotherapy and the patient's insurance provider. The patient is responsible for any copayments, deductibles, or non-covered services as outlined by their insurance policy.
4. All CPT codes and ICD-10 diagnosis codes listed on this Invoice are for billing and insurance purposes only and accurately reflect the services provided.
5. If you have any questions regarding this Invoice or the services provided, please contact our billing department within 14 days of the invoice date.
6. By accepting physiotherapy services, the patient agrees to the terms of payment and acknowledges that they are responsible for verifying their insurance coverage prior to treatment.
7. This Invoice is governed by the laws of the State of Illinois, United States. Any disputes arising from this Invoice shall be resolved in the courts of Cook County, Chicago, Illinois.
8. Chicago Elite Physiotherapy reserves the right to suspend or terminate services if payment obligations are not met in accordance with the agreed-upon terms.
9. All personal health information contained in this Invoice is protected under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
10. Thank you for choosing Chicago Elite Physiotherapy for your rehabilitation needs. We are committed to providing exceptional physiotherapy care in the Chicago metropolitan area.
Authorized Signature:
Michael Thompson, PT, DPT
Lead Physiotherapist
Chicago Elite Physiotherapy
Date: October 24, 2023
Patient Acknowledgment:
___________________________
Signature
Date: _________________
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