Invoice Speech Therapist in United States New York City –Free Word Template Download with AI
Professional Speech Therapist Services
United States New York City
INVOICE NO: ST-NYC-2025-04871Invoice Date: June 15, 2025
Due Date: July 15, 2025 (Net 30)
Service Period: May 1, 2025 – May 31, 2025
Referral Source: Dr. Michael Torres, Pediatric Neurologist, Mount Sinai Hospital, New York, NY
Diagnosis Code (ICD-10): F80.1 – Developmental Expressive Language Disorder
CPM Code: S9780 – Speech Therapy, 30 Minutes
| Session Date | Service Description | Duration | Rate | Amount |
|---|---|---|---|---|
| May 02, 2025 | Initial Speech Therapist Evaluation & Comprehensive Assessment – United States New York City | 60 min | $180.00 | $180.00 |
| May 05, 2025 | Individual Speech Therapy Session – Articulation & Phonological Intervention | 30 min | $120.00 | $120.00 |
| May 09, 2025 | Individual Speech Therapy Session – Expressive Language Development | 30 min | $120.00 | $120.00 |
| May 12, 2025 | Group Speech Therapy Session (4 participants) – Social Communication Skills | 45 min | $95.00 | $95.00 |
| May 16, 2025 | Individual Speech Therapy Session – Fluency & Stuttering Intervention | 30 min | $120.00 | $120.00 |
| May 19, 2025 | Parent Training & Home Program Consultation – Speech Therapist Guidance | 45 min | $140.00 | $140.00 |
| May 23, 2025 | Individual Speech Therapy Session – Receptive Language & Comprehension | 30 min | $120.00 | $120.00 |
| May 27, 2025 | Progress Assessment & Treatment Plan Revision – Speech Therapist Report | 45 min | $150.00 | $150.00 |
| May 30, 2025 | Individual Speech Therapy Session – Generalization & Maintenance Activities | 30 min | $120.00 | $120.00 |
| Description | Amount |
|---|---|
| Subtotal (All Speech Therapist Services) | $1,205.00 |
| Insurance Adjustment (Aetna PPO – 70% Coverage) | -$843.50 |
| Client Co-Pay / Co-Insurance (30%) | $361.50 |
| NYC Sales & Use Tax (8.875% on non-covered items) | $0.00 |
| TOTAL AMOUNT DUE | $361.50 |
Payment Instructions
This Invoice is payable within thirty (30) calendar days from the date of issue. The Speech Therapist practice at Hartwell Speech & Language Therapy Center, located in the United States New York City, accepts the following payment methods:
Check: Payable to "Hartwell Speech & Language Therapy Center" – Mail to 245 Park Avenue South, Suite 1200, New York, NY 10003, United States.
ACH / Bank Transfer: Bank: Chase Manhattan Bank | Routing: 021000021 | Account: 4482-1093-7721
Credit Card: Visa, Mastercard, American Express accepted via secure portal at pay.hartwellspeechnyc.com
Insurance Direct Billing: Aetna PPO claims submitted electronically via Availity clearinghouse. Client responsible for co-pay and co-insurance as noted above.
Notes Regarding This Invoice
This Invoice documents professional Speech Therapist services rendered by Dr. Elizabeth M. Hartwell, a licensed and certified Speech-Language Pathologist (SLP) practicing in the United States New York City. All sessions were conducted in compliance with New York State Education Department regulations (8 NYCRR Part 29) and the American Speech-Language-Hearing Association (ASHA) Code of Ethics. The Speech Therapist provided evidence-based interventions tailored to the client's developmental needs, with progress documented in accordance with HIPAA privacy standards. This Invoice is valid for reimbursement purposes under the client's Aetna PPO health insurance plan. Should any questions arise regarding the line items, service descriptions, or insurance adjustments listed on this Invoice, please contact the billing department at (212) 555-0147 or [email protected] within the payment period.
Terms & Conditions
- This Invoice represents a final accounting of Speech Therapist services for the period specified. No additional charges will be applied for the listed sessions.
- Payment is due within thirty (30) days of the Invoice date. Late payments will incur a 1.5% monthly service charge as permitted under New York State General Obligations Law §5-501.
- The Speech Therapist reserves the right to suspend services if payment remains outstanding beyond forty-five (45) days from the due date, in accordance with the client agreement signed on April 28, 2025.
- All services were performed at the Hartwell Speech & Language Therapy Center facility in the United States New York City, or via telehealth as noted in the session records, in compliance with New York State telehealth regulations (10 NYCRR Part 400).
- Insurance claims are submitted on behalf of the client. The client is responsible for verifying coverage details with their insurance provider. This Invoice reflects estimated adjustments; final reimbursement may vary based on the insurer's adjudication.
- Client records, including this Invoice, are maintained for a minimum of seven (7) years in compliance with New York State Education Law and HIPAA requirements.
- Disputes regarding this Invoice must be submitted in writing within fifteen (15) days of receipt. The Speech Therapist will review and respond within ten (10) business days.
- This Invoice is governed by the laws of the State of New York, United States. Any legal proceedings shall take place in the New York County (Manhattan) courts.
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