Invoice Speech Therapist in Chile Santiago –Free Word Template Download with AI
Dr. Valentina Rojas Mardones
Certified Speech Therapist
RUT: 16.847.293-5
Professional License: FONASA Reg. 4471-S
Av. Providencia 1245, Of. 803
Providencia, Santiago, Chile
Phone: +56 2 2345 6789
Email: [email protected]
Bill To (Client)
Mr. Carlos Andrés Fuentes Herrera
RUT: 15.234.871-K
Av. Apoquindo 3456, Depto. 1204
Las Condes, Santiago, Chile
Phone: +56 9 8765 4321
Email: [email protected]
Service Location
HablaTerapia Centro de Rehabilitación
Av. Providencia 1245, Of. 803
Providencia, Santiago, Chile
Region: Región Metropolitana
Postal Code: 7550000
Description of Speech Therapist Services Rendered| # | Service Description | Date(s) Performed | Sessions | Rate (CLP) | Amount (CLP) |
|---|---|---|---|---|---|
| 1 | Initial Speech and Language Assessment – Comprehensive evaluation of articulation, phonological processes, and receptive/expressive language skills for pediatric patient (age 5) | May 5, 2025 | 1 | $45,000 | $45,000 |
| 2 | Individual Speech Therapy Session – Articulation and phonological remediation targeting /r/, /l/, and /s/ sounds. Evidence-based intervention using auditory discrimination exercises and oral motor therapy | May 8 – Jun 12, 2025 | 8 | $35,000 | $280,000 |
| 3 | Parent Training and Home Program Guidance – Instruction for caregivers on implementing speech therapy exercises at home, including phonological awareness games and articulation practice routines | May 20, 2025 | 1 | $28,000 | $28,000 |
| 4 | Progress Evaluation and Mid-Treatment Report – Reassessment of speech production accuracy, documentation of phonological pattern changes, and updated treatment plan for the next therapy cycle | Jun 10, 2025 | 1 | $38,000 | $38,000 |
| 5 | Interdisciplinary Consultation – Joint session with pediatric neurologist and occupational therapist at Hospital Clínico San Borja Arriagada, Santiago, to coordinate comprehensive rehabilitation plan | Jun 12, 2025 | 1 | $52,000 | $52,000 |
| 6 | Written Clinical Report for School – Detailed speech therapist report for the educational institution (Colegio San Ignacio, Santiago) outlining current speech abilities, recommended accommodations, and IEP modifications | Jun 14, 2025 | 1 | $22,000 | $22,000 |
| Subtotal | $465,000 |
| IVA (19% VAT – Chilean Tax Law) | $88,350 |
| Professional Fee (Speech Therapist – 10%) | $46,500 |
| TOTAL AMOUNT DUE | $599,850 |
Payment Terms and Important Notes
Payment Method: Bank transfer to Banco de Chile, Account No. 12-456789-0, RUT 16.847.293-5. Alternatively, payment may be made via Fonasa reimbursement (Formulario 12) or through private health insurance (Isapre) with the corresponding authorization code.
Payment Deadline: This invoice must be settled within 30 calendar days from the date of issue (July 15, 2025). Late payments will incur a monthly interest rate of 1.5% in accordance with Chilean commercial law (Código de Comercio, Article 593).
Fonasa/Isapre Note: If this invoice is to be submitted for reimbursement through Fonasa or an Isapre provider in Santiago, please ensure that the patient's authorization code and the corresponding procedure codes (CUP) are attached. The Speech Therapist services listed herein correspond to CUP codes 93.10.001 (Speech Therapy – Individual) and 93.10.003 (Speech Assessment).
Confidentiality: All clinical information contained in this invoice and associated reports is protected under Chilean Law 19.628 (Ley de Protección de la Vida Privada) and the regulations of the Colegio de Fonoaudiólogos de Chile. Unauthorized disclosure is prohibited.
Cancellation Policy: Sessions cancelled with less than 24 hours notice will be billed at 50% of the session rate. This policy applies to all Speech Therapist appointments scheduled at the Santiago clinic.
Professional Certification and Compliance StatementThis invoice is issued by a licensed Speech Therapist registered with the Colegio de Fonoaudiólogos de Chile (Registration No. 2847) and authorized to practice in the Región Metropolitana de Santiago. All services rendered comply with the clinical standards established by the Ministerio de Salud de Chile and the professional ethical code of the Chilean Speech-Language Pathology Association. The Speech Therapist services described in this invoice were performed in a clinical setting in Santiago, Chile, in full compliance with national health regulations and patient consent protocols. This document serves as the official fiscal record for the professional services provided and may be used for tax deduction purposes under the Chilean tax code (Ley de Impuesto a la Renta, Article 54).
Dr. Valentina Rojas MardonesSpeech Therapist – Provider
RUT: 16.847.293-5
Santiago, Chile Mr. Carlos A. Fuentes Herrera
Client / Authorized Signatory
RUT: 15.234.871-K
Santiago, Chile
This invoice was generated in Santiago, Chile, in accordance with the requirements of the Servicio de Impuestos Nacionales (SII) for professional service documentation. Invoice ST-2025-04871 is valid for a period of 90 days from the date of issue. For any disputes regarding the services rendered by this Speech Therapist or the terms outlined in this invoice, the parties agree to resolve matters through the courts of Santiago, Chile, in accordance with the Chilean Civil Code. This document constitutes a legally binding fiscal record between the provider and the client. All communications regarding this invoice should be directed to the Speech Therapist's office at the Santiago address listed above. © 2025 HablaTerapia Centro de Rehabilitación – Santiago, Chile. All rights reserved.
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT