Invoice Speech Therapist in United States Houston –Free Word Template Download with AI
Professional Speech Therapy Services — Houston, Texas, United States
PAID IN FULL
Speech Therapist (Provider)
Dr. Margaret L. Whitfield, M.S., CCC-SLP
Whitfield Speech & Language Therapy Center
4820 Westheimer Road, Suite 310
Houston, Texas 77056
United States
Tel: (713) 555-0142
Email: [email protected]
License No.: TX-SLP-2019-44871
Billed To (Client)
Mr. James R. Caldwell
1247 Briar Hollow Lane
Houston, Texas 77024
United States
Tel: (281) 555-0387
Email: [email protected]
Insurance: Blue Cross Blue Shield of Texas
Policy No.: BCBS-TX-9928471
Invoice Number: WSTC-2025-00487
Invoice Date: June 14, 2025
Service Period: May 1, 2025 – May 31, 2025
Due Date: July 14, 2025
Payment Method: Insurance Reimbursement / Direct Billing
Referral Physician: Dr. Alan P. Morrison, MD — Pediatric Neurology, Houston Methodist Hospital
| # | Date of Service | Description of Speech Therapy Service | CPT Code | Hours | Amount (USD) |
|---|---|---|---|---|---|
| 1 | May 02, 2025 | Initial Speech Therapy Evaluation & Diagnostic Assessment — Articulation and phonological processing evaluation for 7-year-old patient. Conducted by licensed Speech Therapist in Houston, Texas. | 92507 | 1.5 | $285.00 |
| 2 | May 06, 2025 | Individual Speech Therapy Session — Articulation remediation targeting /r/, /l/, and /s/ phonemes. Home practice plan provided by Speech Therapist. | 92507 | 1.0 | $190.00 |
| 3 | May 09, 2025 | Individual Speech Therapy Session — Language formulation and expressive language development. Group interaction exercises incorporated. | 92507 | 1.0 | $190.00 |
| 4 | May 13, 2025 | Individual Speech Therapy Session — Fluency therapy techniques for stuttering reduction. Parent coaching component included. | 92507 | 1.0 | $190.00 |
| 5 | May 16, 2025 | Group Speech Therapy Session (4 participants) — Social communication and pragmatic language skills. Facilitated by Speech Therapist in Houston clinic setting. | 92507 | 1.0 | $145.00 |
| 6 | May 20, 2025 | Individual Speech Therapy Session — Reassessment of articulation targets. Progress documentation and treatment plan modification. | 92507 | 1.0 | $190.00 |
| 7 | May 23, 2025 | Telehealth Speech Therapy Session — Remote articulation practice and homework review. Conducted via HIPAA-compliant platform by Speech Therapist. | 92507 | 1.0 | $175.00 |
| 8 | May 27, 2025 | Individual Speech Therapy Session — Oral-motor exercises and swallowing facilitation. Coordination with pediatric ENT specialist in Houston, United States. | 92507 | 1.0 | $190.00 |
| 9 | May 30, 2025 | Monthly Progress Report & Care Coordination — Comprehensive written report to referring physician. Includes Speech Therapist clinical notes, goal attainment data, and recommended next-phase interventions. | 92507 | 0.5 | $95.00 |
| Subtotal (9 sessions) | $1,650.00 |
| Insurance Adjustment (BCBS-TX) | -$1,087.50 |
| Applicable Tax (0% — Medical Exempt, State of Texas) | $0.00 |
| Patient Responsibility (Balance Due) | $562.50 |
Important Notes & Payment Terms
1. This Invoice has been issued by a licensed Speech Therapist operating in compliance with all regulations set forth by the Texas State Board of Examiners of Speech-Language Pathologists and Audiologists. All services were rendered in Houston, Texas, United States.
2. The patient responsibility amount of $562.50 is due within thirty (30) days of the Invoice date. Payment may be made via check, credit card (Visa, MasterCard, American Express), or electronic bank transfer. Please reference Invoice Number WSTC-2025-00487 on all correspondence.
3. This Speech Therapist practice accepts most major insurance carriers operating in the Houston metropolitan area, including Blue Cross Blue Shield of Texas, Aetna, Cigna, UnitedHealthcare, and Humana. Pre-authorization was obtained prior to the initial evaluation session.
4. All speech therapy services documented on this Invoice were performed in accordance with the American Speech-Language-Hearing Association (ASHA) Code of Ethics and the clinical practice guidelines established for the Houston, United States region.
5. A copy of this Invoice and the associated clinical documentation is available upon request. The Speech Therapist, Dr. Whitfield, is available for a brief telehealth consultation should the client or referring physician require clarification of any line item on this Invoice.
6. Late payments exceeding the thirty-day window will be subject to a 1.5% monthly interest charge as permitted under Texas Business & Commerce Code. Please contact the billing office at (713) 555-0142 to arrange a payment plan if needed.
7. This Invoice does not constitute a guarantee of specific therapeutic outcomes. The Speech Therapist provides evidence-based interventions tailored to the individual needs of each patient within the Houston, United States service area.
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