Invoice Physiotherapist in United States Los Angeles –Free Word Template Download with AI
1234 Wilshire Boulevard, Suite 400
Los Angeles, CA 90017
United States
Phone: (323) 555-0198 | Fax: (323) 555-0199
Email: [email protected]
License No.: PT-88421-LA
Invoice Number: INV-2023-10-045
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Period: October 1, 2023 - October 23, 2023
Bill To (Patient)Mr. James Anderson
789 Sunset Boulevard, Apt 12B
Los Angeles, CA 90028
United States
Patient ID: PT-JA-9921
Date of Birth: 05/12/1985
Pay From (Insurance / Payer)Blue Cross Blue Shield of California
Policy Number: BCBS-CA-7742-991
Group Number: GRP-LA-5500
Subscriber Name: James Anderson
Relationship: Self
Detailed Services Rendered| Date | CPT Code | Description of Physiotherapy Services | Units | Rate ($) | Amount ($) |
|---|---|---|---|---|---|
| Oct 02, 2023 | 97161 | Initial Physical Therapy Evaluation: Comprehensive assessment of musculoskeletal condition, including gait analysis and range of motion testing in Los Angeles clinic. | 1 | 185.00 | 185.00 |
| Oct 04, 2023 | 97110 | Therapeutic Exercise: Strengthening and flexibility exercises for lower back and core stability. Supervised session by licensed Physiotherapist. | 1 | 110.00 | 110.00 |
| Oct 06, 2023 | 97140 | Manual Therapy: Soft tissue mobilization and joint manipulation techniques to alleviate pain and improve mobility. | 1 | 125.00 | 125.00 |
| Oct 09, 2023 | 97032 | Electrical Stimulation (Attended): Neuromuscular electrical stimulation for pain management and muscle re-education. | 1 | 95.00 | 95.00 |
| Oct 11, 2023 | 97110 | Therapeutic Exercise: Continued progressive resistance training and balance exercises tailored to patient's recovery goals. | 1 | 110.00 | 110.00 |
| Oct 13, 2023 | 97112 | N Neuromuscular Re-education: Training for balance, coordination, and kinesthetic sense to prevent future injury. | 1 | 115.00 | 115.00 |
| Oct 16, 2023 | 97140 | Manual Therapy: Myofascial release and trigger point therapy focusing on lumbar region and gluteal muscles. | 1 | 125.00 | 125.00 |
| Oct 18, 2023 | 97110 | Therapeutic Exercise: Advanced functional movement training and sport-specific drills for return to activity. | 1 | 110.00 | 110.00 |
| Oct 20, 2023 | 97162 | Re-evaluation: Intermediate Physical Therapy Evaluation to assess progress, modify treatment plan, and determine continued medical necessity. | 1 | 145.00 | 145.00 |
| Oct 23, 2023 | 97110 | Therapeutic Exercise: Final session of current billing period focusing on home exercise program instruction and self-management strategies. | 1 | 110.00 | 110.00 |
Please remit payment for the outstanding balance of $120.00 by the due date indicated above. Payments can be made via:
- Online: Visit our secure patient portal at https://portal.westsidephysio-la.com
- Check: Make checks payable to "Westside Physiotherapy & Rehabilitation" and mail to the address listed in the header.
- Credit Card: Call our billing department at (323) 555-0198 to process payment over the phone.
Important Notes & Terms of Service
This Invoice represents the professional services provided by a licensed Physiotherapist in accordance with the regulations of the Physical Therapy Board of California. All treatments were administered at our Los Angeles, United States facility. The CPT codes listed are standard Current Procedural Terminology codes used for billing purposes in the United States healthcare system.
Insurance Information: We have submitted this claim to your primary insurance provider, Blue Cross Blue Shield of California. The amount due reflects the patient's responsibility after insurance adjustments and payments. Please verify your Explanation of Benefits (EOB) from your insurer. If you have questions about your coverage, please contact your insurance provider directly.
Late Payments: Accounts not paid within 30 days of the invoice date may be subject to a late fee of 1.5% per month or the maximum allowed by California law, whichever is less. Persistent non-payment may result in the account being referred to a collection agency.
Disputes: If you believe there is an error on this Invoice, please contact our billing department within 15 days of receipt. Provide your Invoice Number (INV-2023-10-045) and a detailed description of the discrepancy.
Privacy: Your health information is protected under HIPAA (Health Insurance Portability and Accountability Act). This Invoice contains protected health information and should be handled confidentially.
Authorized Signature (Physiotherapist)
Dr. Sarah Mitchell, DPT
License No.: PT-88421-LA
Date: October 24, 2023
Patient Acknowledgment
Signature:
Date:
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