Invoice Speech Therapist in Brazil Rio de Janeiro –Free Word Template Download with AI
Speech Therapist Practice
Rua das Acácias, 1247 – Sala 302
Barra da Tijuca, Rio de Janeiro – RJ
Brazil, CEP 22793-000
CNPJ: 12.345.678/0001-90
Phone: +55 (21) 3456-7890
Email: [email protected]
Billed To (Client)
Name: Maria Helena Santos Oliveira
CPF: 123.456.789-00
Address: Av. das Américas, 5000 – Bloco C, Apto 1204
Neighborhood: Barra da Tijuca
City: Rio de Janeiro – RJ, Brazil
CEP: 22631-000
Email: [email protected]
Phone: +55 (21) 99876-5432
Service Provider
Speech Therapist: Dra. Camila Ferreira Lima
Professional Registration: CREFONO-2ª Região – 45.678
Specialization: Pediatric & Adult Speech-Language Pathology
Clinic: Clínica Fono Rio
Location: Rio de Janeiro, State of Rio de Janeiro, Brazil
Supervising Physician: Dr. Ricardo Mendes (CRM-RJ 112.345)
| # | Description of Speech Therapy Service | Date(s) | Sessions | Rate (BRL) | Subtotal (BRL) | CBHPM Code |
|---|---|---|---|---|---|---|
| 1 | Individual Speech Therapy Session – Articulation and Phonological Disorders (Child, age 7). Assessment and corrective exercises targeting consonant cluster production and syllable structure. | Jan 03, 10, 17, 24 | 4 | R$ 280,00 | R$ 1.120,00 | 02.02.01-0 |
| 2 | Speech-Language Evaluation – Comprehensive diagnostic assessment including oral motor examination, language comprehension, expressive language, and pragmatic communication analysis. Includes written report. | Jan 06 | 1 | R$ 450,00 | R$ 450,00 | 02.02.02-8 |
| 3 | Group Speech Therapy Session – Social Communication and Pragmatics (4 participants). Facilitated by the Speech Therapist in a structured group setting at the Rio de Janeiro clinic. | Jan 08, 15, 22, 29 | 4 | R$ 180,00 | R$ 720,00 | 02.02.03-6 |
| 4 | Home Visit Speech Therapy – In-home session at client residence in Barra da Tijuca, Rio de Janeiro. Parent/caregiver training on home-based articulation exercises and environmental modification strategies. | Jan 12, 26 | 2 | R$ 350,00 | R$ 700,00 | 02.02.04-4 |
| 5 | Therapeutic Materials and Resources – Customized phonological intervention materials, visual aids, and digital therapy app license (3-month subscription) provided by the Speech Therapist. | Jan 03 | 1 | R$ 120,00 | R$ 120,00 | N/A |
| 6 | Telehealth Speech Therapy Session – Remote session conducted via secure video platform. Follow-up on articulation progress and assignment of new therapeutic activities. Compliant with CREFONO telehealth guidelines in Brazil. | Jan 18, 25 | 2 | R$ 220,00 | R$ 440,00 | 02.02.05-2 |
| Subtotal | R$ 3.550,00 |
| Insurance Discount (Unimed RJ – 40%) | - R$ 1.420,00 |
| Amount Due (Co-pay) | R$ 2.130,00 |
| ISS Tax (5% – Rio de Janeiro Municipal Tax) | R$ 106,50 |
| ICMS (Applicable Digital Services – 18%) | R$ 21,60 |
| TOTAL AMOUNT DUE | R$ 2.258,10 |
Payment Instructions
Bank: Banco do Brasil S.A.
Account Holder: Clínica Fono Rio – Dra. Camila Ferreira Lima
Account Number (Conta Corrente): 12.345-6
Branch (Agência): 0987-6
Routing (CNPJ): 12.345.678/0001-90
PIX Key: [email protected]
Accepted Methods: Bank Transfer (TED/DOC), PIX, Credit Card (up to 3 installments), Boleto Bancário
Payment Due: Within 30 days of invoice date (by February 14, 2025). Late payments are subject to a 2% penalty plus 1% monthly interest as per Brazilian consumer law (Código de Defesa do Consumidor, Art. 52).
Important Notes and Terms
1. This invoice is issued in accordance with the Brazilian National Health Surveillance Agency (ANVISA) regulations and the professional code of ethics of the CREFONO (Conselho Federal de Fonoaudiologia), 2ª Região – Rio de Janeiro.
2. All speech therapy services described in this invoice were performed by a licensed Speech Therapist (Fonoaudióloga) registered with the CREFONO-2ª Região. The professional registration number is displayed above for verification purposes.
3. The services rendered at the Clínica Fono Rio facility in Rio de Janeiro, Brazil, comply with all applicable state and municipal health regulations. The clinic operates under Alvará Sanitário No. 2024-08765 issued by the Secretaria Municipal de Saúde do Rio de Janeiro.
4. Telehealth sessions were conducted in compliance with Resolution CFF-01/2020 and the CREFONO guidelines for remote speech-language pathology services in Brazil.
5. The ISS (Imposto Sobre Serviços) tax of 5% is levied by the Prefeitura da Cidade do Rio de Janeiro on services rendered within the municipality. The ICMS applies to the digital therapy app license component.
6. This invoice serves as the official fiscal document (Nota Fiscal de Serviço) for the services rendered. A digital copy in XML format is available upon request for insurance reimbursement purposes.
7. The client acknowledges that all speech therapy sessions were conducted as part of a structured treatment plan developed by the Speech Therapist in consultation with the supervising physician. Progress reports are issued monthly.
8. For any discrepancies or questions regarding this invoice, please contact the billing department of Clínica Fono Rio within 15 business days of the issue date. Contact: [email protected] or +55 (21) 3456-7890.
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