Invoice Physiotherapist in United States San Francisco –Free Word Template Download with AI
1234 Market Street, Suite 400
San Francisco, CA 94103
United States
Phone: (415) 555-0199
Email: [email protected]
NPI: 1234567890 | CA License: PT12345
Invoice Number: INV-SF-2023-0089
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Period: October 1, 2023 - October 24, 2023
Bill To (Patient)
Mr. John Doe
567 Valencia Street, Apt 12B
San Francisco, CA 94110
United States
Phone: (415) 555-0123
DOB: 05/15/1985
Policy ID: HMO-99887766
Pay To (Provider)
Bay Area Physiotherapy & Rehabilitation
Attn: Accounts Receivable
1234 Market Street, Suite 400
San Francisco, CA 94103
United States
Bank: Wells Fargo Bank
Routing: 121000248
Account: 9876543210
| Date | CPT Code | Description of Physiotherapy Services | Units | Rate | Amount |
|---|---|---|---|---|---|
| Oct 02, 2023 | 97161 | Physical Therapy Evaluation: Low complexity. Initial assessment of lumbar spine pathology and functional mobility limitations. | 1 | $150.00 | $150.00 |
| Oct 05, 2023 | 97110 | Therapeutic Exercise: Training to improve strength, flexibility, muscle endurance, and range of motion. Focus on core stabilization. | 1 | $95.00 | $95.00 |
| Oct 05, 2023 | 97140 | Manual Therapy: Hands-on techniques to mobilize joints and soft tissues. Myofascial release applied to paraspinal muscles. | 1 | $95.00 | $95.00 |
| Oct 09, 2023 | 97032 | Electrical Stimulation (Attended): Neuromuscular electrical stimulation for pain management and muscle re-education. | 1 | $45.00 | $45.00 |
| Oct 12, 2023 | 97110 | Therapeutic Exercise: Progressive resistance training utilizing resistance bands and body weight exercises. | 1 | $95.00 | $95.00 |
| Oct 12, 2023 | 97035 | Ultrasound Therapy: Therapeutic ultrasound to promote tissue healing and reduce inflammation in the lower back region. | 1 | $45.00 | $45.00 |
| Oct 16, 2023 | 97112 | N Neuromuscular Re-education: Activities designed to improve kinesthetic sense, posture, balance, and coordination. | 1 | $95.00 | $95.00 |
| Oct 19, 2023 | 97140 | Manual Therapy: Joint mobilization and soft tissue mobilization to address restricted range of motion in the lumbar spine. | 1 | $95.00 | $95.00 |
| Oct 23, 2023 | 97110 | Therapeutic Exercise: Functional training exercises simulating daily activities to enhance return to work capabilities. | 1 | $95.00 | $95.00 |
Payment Terms and Conditions
This Invoice represents the professional fees for physiotherapy services rendered by Bay Area Physiotherapy & Rehabilitation, located in San Francisco, California, United States. Payment is due within 30 days of the invoice date. Late payments may be subject to a 1.5% monthly finance charge.
Insurance Information: Please note that the amounts listed above are our standard professional fees. The "Insurance Adjustment" and "Insurance Payment" figures are estimates based on your current policy information. The final patient responsibility may vary depending on your specific deductible, co-pay, and co-insurance requirements. We accept most major insurance plans operating in the San Francisco Bay Area.
Payment Methods: We accept payments via check, credit card (Visa, MasterCard, Amex), debit card, and HSA/FSA cards. Checks should be made payable to "Bay Area Physiotherapy & Rehabilitation" and mailed to the address listed in the "Pay To" section. Online payments can be made securely through our patient portal at www.bayareaphysio.com/pay.
Disputes: If you have any questions regarding this Invoice or the services provided, please contact our billing department at (415) 555-0199 or email [email protected] within 15 days of receipt. Please reference Invoice Number INV-SF-2023-0089 in all correspondence.
Privacy Notice: In accordance with HIPAA regulations and California state law, your personal health information is kept strictly confidential. This Invoice contains protected health information (PHI) and should be handled accordingly.
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