Invoice Speech Therapist in United States Chicago –Free Word Template Download with AI
1247 N. Michigan Avenue, Suite 850
Chicago, Illinois 60610, United States
Phone: (312) 555-0198 | Fax: (312) 555-0199
Email: [email protected]
NPI: 1497823651 | IL License: SL-2019-4482
Licensed Speech Therapist PracticeBilled To (Patient / Guardian)
Mr. Jonathan R. Whitfield
2847 W. Fullerton Avenue, Unit 3B
Chicago, Illinois 60647, United States
Phone: (773) 555-0342
Email: [email protected]
DOB: 03/14/2019 (Age: 6)
Insurance / Payer
Blue Cross Blue Shield of Illinois
Member ID: BCS-IL-88234567
Group Number: GRP-2025-11982
Policy Type: PPO – Family Plan
Referring Physician: Dr. Alan M. Torres, MD
Referral Expires: 12/31/2025
| Date | Service Description | CPT Code | Units | Rate | Amount |
|---|---|---|---|---|---|
| 05/02/2025 | Individual Speech Therapy – Articulation & Phonology (30 min) | 92507 | 1 | $145.00 | $145.00 |
| 05/05/2025 | Individual Speech Therapy – Language Comprehension & Expression (30 min) | 92507 | 1 | $145.00 | $145.00 |
| 05/09/2025 | Individual Speech Therapy – Fluency / Stuttering Intervention (30 min) | 92507 | 1 | $145.00 | $145.00 |
| 05/12/2025 | Group Speech Therapy – Social Pragmatics (20 min, 4 participants) | 92508 | 1 | $110.00 | $110.00 |
| 05/16/2025 | Individual Speech Therapy – Oral Motor & Feeding Assessment (45 min) | 92526 | 1 | $185.00 | $185.00 |
| 05/19/2025 | Individual Speech Therapy – Articulation & Phonology (30 min) | 92507 | 1 | $145.00 | $145.00 |
| 05/23/2025 | Individual Speech Therapy – Language Comprehension & Expression (30 min) | 92507 | 1 | $145.00 | $145.00 |
| 05/26/2025 | Group Speech Therapy – Social Pragmatics (20 min, 4 participants) | 92508 | 1 | $110.00 | $110.00 |
| 05/30/2025 | Individual Speech Therapy – Fluency / Stuttering Intervention (30 min) | 92507 | 1 | $145.00 | $145.00 |
| 05/31/2025 | Comprehensive Speech-Language Evaluation & Report (90 min) | 92526 | 1 | $320.00 | $320.00 |
| Subtotal (10 sessions) | $1,690.00 |
| Insurance Adjustment (BCS PPO) | ($584.20) |
| Applicable Tax (0% – Medical Exempt, IL) | $0.00 |
| Co-Pay / Co-Insurance (20%) | $221.36 |
| Patient Responsibility Due | $221.36 |
Payment Terms & Instructions
This Invoice is payable within 30 days of the date of issue. The Speech Therapist at Chicago Speech & Language Center accepts the following payment methods: credit card (Visa, Mastercard, American Express), debit card, personal check, ACH bank transfer, and HSA/FSA cards.
For credit card payments, please call our billing office at (312) 555-0198 between 9:00 AM and 5:00 PM Central Time, Monday through Friday. For check payments, mail to: Chicago Speech & Language Center, Attn: Billing Department, 1247 N. Michigan Avenue, Suite 850, Chicago, IL 60610, United States.
A late payment fee of 1.5% per month will be applied to any balance remaining unpaid after the due date of July 12, 2025. Please reference Invoice Number INV-2025-04872 on all correspondence and remittances.
Important Notes
1. All services rendered by our licensed Speech Therapist are performed in compliance with the Illinois Department of Financial & Professional Regulation (IDFPR) and the American Speech-Language-Hearing Association (ASHA) Code of Ethics.
2. This Invoice covers services provided during the period of May 1, 2025, through May 31, 2025, at our clinic located in the United States Chicago metropolitan area. All sessions were conducted in person at our Michigan Avenue facility unless otherwise noted.
3. The comprehensive evaluation report (CPT 92526, dated 05/31/2025) has been submitted to the referring physician, Dr. Alan M. Torres, and a copy is available upon request from our front desk.
4. If you have any questions regarding this Invoice, the services rendered by your Speech Therapist, or your insurance coverage details, please contact our billing coordinator, Ms. Patricia Nguyen, at (312) 555-0198 ext. 4 or [email protected].
5. This document serves as an official Invoice for medical services and is valid for tax and insurance reimbursement purposes in the State of Illinois, United States.
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