Invoice Physiotherapist in United States Miami –Free Word Template Download with AI
1200 Brickell Avenue, Suite 400
Miami, FL 33131, United States
Phone: (305) 555-0199 | Email: [email protected]
Tax ID (EIN): 59-1234567
Invoice Number: INV-2023-10-884
Date Issued: October 24, 2023
Due Date: November 24, 2023
Payment Method: Credit Card, Check, or Bank Transfer
BILL TO:
Patient Name: Jonathan Doe
Address: 450 Alton Road, Apt 12B
City/State/Zip: Miami Beach, FL 33139, United States
Insurance Provider: Blue Cross Blue Shield of Florida
Policy Number: BCBS-FL-99887766
Group Number: GRP-554433
SERVICE SUMMARY:
Treating Physiotherapist: Dr. Elena Rodriguez, PT, DPT
License Number: FL-PT-445566
Diagnosis Code (ICD-10): M54.5 (Low back pain)
Referring Physician: Dr. Alan Smith, MD
Service Period: October 1, 2023 - October 20, 2023
| Date of Service | Description of Physiotherapy Services | CPT Code | Qty | Amount (USD) |
|---|---|---|---|---|
| Oct 02, 2023 | Initial Evaluation: Comprehensive assessment of musculoskeletal condition, history taking, and development of a personalized treatment plan tailored for recovery in the Miami climate. | 97161 | 1 | $185.00 |
| Oct 05, 2023 | Therapeutic Exercise: Training for strength, flexibility, coordination, and balance. Focus on core stabilization and lumbar support. | 97110 | 1 | $65.00 |
| Oct 05, 2023 | Manual Therapy: Hands-on techniques to manipulate soft tissues and joints to improve mobility and reduce pain. | 97140 | 1 | $70.00 |
| Oct 09, 2023 | Therapeutic Exercise: Continued progression of resistance training and functional movement patterns. | 97110 | 1 | $65.00 |
| Oct 09, 2023 | Ultrasound Therapy: Application of ultrasonic energy to promote healing in deep tissues. | 97035 | 1 | $55.00 |
| Oct 12, 2023 | Manual Therapy: Joint mobilization and soft tissue massage to alleviate stiffness. | 97140 | 1 | $70.00 |
| Oct 12, 2023 | Therapeutic Exercise: Focus on posture correction and ergonomic education for office work. | 97110 | 1 | $65.00 |
| Oct 16, 2023 | Therapeutic Exercise: Advanced functional training preparing patient for return to daily activities. | 97110 | 1 | $65.00 |
| Oct 16, 2023 | Electrical Stimulation: Use of electrical current to manage pain and stimulate muscle contraction. | 97014 | 1 | $50.00 |
| Oct 20, 2023 | Re-evaluation: Assessment of progress, modification of treatment plan, and discharge planning. | 97162 | 1 | $145.00 |
| Subtotal: | $835.00 |
| Insurance Adjustment (Est.): | -$450.00 |
| Insurance Payment Applied: | -$300.00 |
| Patient Responsibility: | $85.00 |
Payment Instructions & Notes:
Thank you for choosing Miami Elite Physiotherapy. This invoice represents the detailed breakdown of services rendered by our licensed physiotherapist in Miami, United States. Please note that all amounts are listed in United States Dollars (USD).
Payment Options:
- Online: Visit our secure patient portal at www.miamielitephysio.com/pay.
- Check: Make checks payable to "Miami Elite Physiotherapy" and mail to the address listed in the header.
- In-Person: Payments accepted at our Miami office during business hours (Mon-Fri, 8:00 AM - 6:00 PM).
Insurance Information:
We have submitted the necessary claims to your insurance provider. The "Insurance Adjustment" reflects the difference between our billed rate and the allowed amount by your plan. The "Patient Responsibility" is the remaining balance due after insurance processing. If you have questions regarding your benefits or coverage, please contact your insurance provider directly.
Late Fees:
Payments not received by the due date may be subject to a late fee of 1.5% per month on the outstanding balance, in accordance with Florida state regulations.
Legal Disclaimer: This document serves as an official invoice for physiotherapy services provided in the State of Florida, United States. By receiving these services, the patient acknowledges that they have read and understood the privacy practices and financial policies of Miami Elite Physiotherapy. All treatment plans are designed by a qualified physiotherapist licensed to practice in the United States. This invoice is generated in compliance with federal and state billing regulations. Any disputes regarding this invoice must be raised within 30 days of the issue date. For legal purposes, this document is binding and represents the financial agreement between the provider and the patient for the specified period.
Authorized Signature (Physiotherapist)Dr. Elena Rodriguez, PT, DPT Patient Signature (Acknowledgment)
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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