Invoice Physiotherapist in United States New York City –Free Word Template Download with AI
123 Park Avenue, Suite 400
New York, NY 10017
United States New York City
Phone: (212) 555-0199
Email: [email protected]
NPI: 1234567890 | NY State License: PT-987654
Invoice Number: INV-2023-10-045
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Period: October 1, 2023 - October 24, 2023
Bill To:
Mr. Jonathan A. Sterling
45 West 72nd Street, Apt 12B
New York, NY 10023
United States New York City
Phone: (646) 555-0123
Insurance: Blue Cross Blue Shield of NY
Policy #: BCBS-NY-99887766
Group #: GRP-554433
Service Provider:
Dr. Elena Rostova, DPT, OCS
Board Certified Orthopedic Clinical Specialist
Manhattan Elite Physiotherapy
123 Park Avenue, Suite 400
New York, NY 10017
United States New York City
| # | Date of Service | Description of Physiotherapy Services | CPT Code | Units | Amount (USD) |
|---|---|---|---|---|---|
| 1 | Oct 02, 2023 | Initial Evaluation: Comprehensive musculoskeletal assessment for lower back pain and sciatica. Includes history, physical exam, and treatment plan formulation. | 97161 | 1 | $250.00 |
| 2 | Oct 05, 2023 | Therapeutic Exercise: Core stabilization and lumbar strengthening exercises tailored for post-acute recovery. 30-minute session. | 97110 | 1 | $120.00 |
| 3 | Oct 05, 2023 | Manual Therapy: Joint mobilization and soft tissue manipulation for lumbar spine and hip region. 15-minute session. | 97140 | 1 | $85.00 |
| 4 | Oct 09, 2023 | Therapeutic Exercise: Progressive resistance training and flexibility routines. 30-minute session. | 97110 | 1 | $120.00 |
| 5 | Oct 09, 2023 | Neuromuscular Reeducation: Balance and proprioception training for gait improvement. 15-minute session. | 97112 | 1 | $90.00 |
| 6 | Oct 12, 2023 | Therapeutic Exercise: Advanced core strengthening and functional movement patterns. 30-minute session. | 97110 | 1 | $120.00 |
| 7 | Oct 12, 2023 | Manual Therapy: Myofascial release and trigger point therapy for paraspinal muscles. 15-minute session. | 97140 | 1 | $85.00 |
| 8 | Oct 16, 2023 | Therapeutic Exercise: Functional training for daily activities and return-to-work preparation. 30-minute session. | 97110 | 1 | $120.00 |
| 9 | Oct 16, 2023 | Electrical Stimulation: Neuromuscular electrical stimulation for pain management and muscle activation. 15-minute session. | 97014 | 1 | $75.00 |
| 10 | Oct 19, 2023 | Therapeutic Exercise: Maintenance program and home exercise instruction. 30-minute session. | 97110 | 1 | $120.00 |
| 11 | Oct 19, 2023 | Manual Therapy: Final adjustment and mobility assessment. 15-minute session. | 97140 | 1 | $85.00 |
| 12 | Oct 23, 2023 | Re-evaluation: Progress assessment and treatment plan modification. 20-minute session. | 97162 | 1 | $180.00 |
Important Notes & Payment Instructions:
This invoice represents professional physiotherapy services rendered in accordance with the standards of practice in the United States New York City. All services were provided by licensed physical therapists under the supervision of Dr. Elena Rostova, DPT, OCS.
Payment is due within 30 days of the invoice date. Please make checks payable to "Manhattan Elite Physiotherapy" and mail to the address listed above. For electronic payments, please contact our billing department at [email protected].
If you have any questions regarding this invoice or your insurance coverage, please do not hesitate to contact us. We are committed to providing transparent billing practices and excellent patient care.
Note: A credit of $150.00 has been applied to your account and will be used for future services or refunded upon request.
Authorized Signature:
Dr. Elena Rostova, DPT, OCS
Manhattan Elite Physiotherapy
Patient Acknowledgment:
I acknowledge receipt of this invoice and understand the charges listed above.
Signature: _________________________
Date: _________________________
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