Invoice Speech Therapist in United States Los Angeles –Free Word Template Download with AI
4520 Wilshire Boulevard, Suite 310
Los Angeles, California 90016, United States
Phone: (213) 555-0187 | Email: [email protected]
CA License No. SLP-2019-4482 | NPI: 1740829365
Billed To
Client Name: Mr. Jonathan R. Whitfield
Address: 2847 Sunset Drive, Apt 12B
Los Angeles, California 90048, United States
Phone: (310) 555-7743
Email: [email protected]
Insurance Provider: Blue Cross Blue Shield of California
Policy Number: BCBS-CA-88291044
Service Provider
Speech Therapist: Dr. Elena M. Vasquez, M.S., CCC-SLP
Specialty: Pediatric & Adult Speech-Language Pathology
License: California SLP License #SLP-2019-4482
ASHA Certificate: CCC-SLP #2019-00341
Practice Location: Los Angeles, United States
| Date of Service | Description of Speech Therapy Service | CPT Code | Units | Rate | Amount |
|---|---|---|---|---|---|
| 05/05/2025 | Individual Speech Therapy Session – Articulation & Phonological Intervention (45 min) | 92507 | 1 | $185.00 | $185.00 |
| 05/12/2025 | Individual Speech Therapy Session – Language Comprehension & Expression Therapy (45 min) | 92526 | 1 | $195.00 | $195.00 |
| 05/19/2025 | Individual Speech Therapy Session – Fluency Stuttering Intervention & Management (45 min) | 92524 | 1 | $195.00 | $195.00 |
| 05/26/2025 | Individual Speech Therapy Session – Voice Therapy & Resonance Training (45 min) | 92509 | 1 | $185.00 | $185.00 |
| 06/02/2025 | Comprehensive Speech-Language Evaluation & Diagnostic Assessment (90 min) | 92526 | 2 | $195.00 | $390.00 |
| 06/09/2025 | Individual Speech Therapy Session – Swallowing (Dysphagia) Therapy & Oral Motor Exercises (45 min) | 92507 | 1 | $185.00 | $185.00 |
| Subtotal (Professional Services) | $1,335.00 |
| Insurance Adjustment (BCBS-CA) | -$412.00 |
| Client Co-Insurance (20%) | $182.60 |
| Client Co-Pay (Per Visit × 6) | $120.00 |
| California Sales Tax (Exempt – Medical) | $0.00 |
| Amount Due | $302.60 |
Invoice Notes & Payment Instructions
This Invoice reflects all Speech Therapist services rendered by Dr. Elena M. Vasquez at the ClearVoice Speech & Language Center located in Los Angeles, United States, during the billing period of May 5, 2025 through June 9, 2025. All sessions were conducted in person at our Wilshire Boulevard clinic facility.
Please remit payment of $302.60 within thirty (30) days of the Invoice issue date. Payment may be made via check payable to "ClearVoice Speech & Language Center," ACH bank transfer, or credit card (Visa, Mastercard, American Express). A convenience fee of 2.9% applies to credit card transactions processed through our online Invoice portal.
For questions regarding this Invoice or your Speech Therapist session details, please contact our billing department at (213) 555-0187, Monday through Friday, 9:00 AM to 5:00 PM Pacific Time. You may also email [email protected] with your Invoice number INV-2025-04872 in the subject line.
Terms, Conditions & Legal Notice
1. This Invoice constitutes a formal request for payment for Speech Therapist professional services provided in the state of California, United States. All services were delivered in compliance with California Board of Registered Nursing and Speech-Language Pathology regulations and the American Speech-Language-Hearing Association (ASHA) Code of Ethics.
2. The Speech Therapist named on this Invoice, Dr. Elena M. Vasquez, holds an active California license and ASHA certification. All clinical services were performed in accordance with the scope of practice defined by the California Business and Professions Code, Section 2800 et seq.
3. Late payments on this Invoice will incur a monthly interest charge of 1.5% on the outstanding balance after the due date of July 12, 2025. Accounts remaining unpaid beyond sixty (60) days from the Invoice date may be referred to a licensed United States collection agency operating in Los Angeles, California.
4. This Invoice does not constitute a guarantee of clinical outcomes. Speech therapy progress varies by individual. The Speech Therapist and ClearVoice Speech & Language Center shall not be held liable for any indirect, incidental, or consequential damages arising from the services described herein.
5. All personal health information contained in this Invoice is protected under the Health Insurance Portability and Accountability Act (HIPAA) and California Confidentiality of Medical Information Act (CMIA). Unauthorized disclosure of this Invoice to third parties without written client consent is prohibited.
6. This Invoice is governed by the laws of the State of California, United States. Any disputes arising from this Invoice or the associated Speech Therapist services shall be resolved through binding arbitration in Los Angeles County, California, in accordance with the California Arbitration Act.
7. The client acknowledges that all Speech Therapist sessions listed on this Invoice were pre-authorized or fall within the benefits covered by their insurance plan. The client is responsible for any deductibles, co-pays, or non-covered charges as itemized above.
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