Quotation Estimate Occupational Therapist in United States Los Angeles –Free Word Template Download with AI

1. Purpose of This Quotation Estimate

This Quotation Estimate is issued by Westside Rehabilitation & Occupational Therapy Group, LLC to provide a comprehensive, itemized financial projection for the professional services of a licensed Occupational Therapist operating within the United States Los Angeles metropolitan area. This document serves as a formal cost estimate and does not constitute a binding contract until accepted in writing by the requesting party. All pricing reflects current 2025 market rates for Occupational Therapist services in the Los Angeles, California region, in compliance with the California Board of Occupational Therapy and applicable United States federal healthcare regulations.

2. Scope of Occupational Therapist Services

The Occupational Therapist services outlined in this Quotation Estimate encompass a full continuum of care designed to restore, maintain, or improve the functional independence of the client in activities of daily living (ADLs), instrumental activities of daily living (IADLs), and vocational or recreational tasks. Services are delivered by a Licensed Occupational Therapist (OTR) or a Certified Occupational Therapy Assistant (COTA) under the direct supervision of the OTR, in accordance with the scope of practice established by the California Department of Consumer Affairs and the National Board of Certification and Recertification for Occupational Therapists (NBCOT).

3. Itemized Cost Breakdown

4. Insurance & Billing Information

This Quotation Estimate is provided for informational and pre-authorization purposes. Westside Rehabilitation & Occupational Therapy Group, LLC accepts most major insurance carriers operating in the United States Los Angeles area, including but not limited to Medicare, Medi-Cal, Blue Shield of California, Kaiser Permanente, UnitedHealthcare, Aetna, and Cigna. The Occupational Therapist services listed above are billed using the appropriate CPT codes (e.g., 97110, 97112, 97113, 97530, 97535, 97537, 97541, 97542, 97545, 97546, 97550) and ICD-10 diagnostic codes as applicable. The client is responsible for any applicable deductibles, copayments, coinsurance, or non-covered services as determined by their specific insurance plan. A superbill or itemized statement will be provided upon request for out-of-network reimbursement.

5. Terms and Conditions of This Quotation Estimate

1. This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, rates may be subject to revision based on current Occupational Therapist market pricing in the United States Los Angeles area.
2. All services must be performed by or under the direct supervision of a Licensed Occupational Therapist (OTR) registered with the California Board of Occupational Therapy. The Occupational Therapist assigned to this case will be identified in writing prior to the initial evaluation.
3. The estimated total cost is based on the projected frequency and duration outlined in Section 3. Actual costs may vary depending on the client's clinical progress, physician orders, insurance authorization limits, or changes in the treatment plan as determined by the treating Occupational Therapist.
4. A minimum of 48 hours' written notice is required to reschedule or cancel any Occupational Therapy appointment. Cancellations made within 24 hours of the scheduled session may incur a 50% fee of the applicable unit rate.
5. Home-based Occupational Therapy services within Los Angeles County (including the cities of Los Angeles, Culver City, Santa Monica, West Hollywood, Beverly Hills, and surrounding communities) are included at the rates specified. Travel to locations outside Los Angeles County will be assessed at an additional mileage rate of $0.67 per mile, in accordance with the 2025 United States IRS standard mileage rate.
6. All clinical records, progress notes, and discharge summaries generated during the course of Occupational Therapy treatment are maintained in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and California Confidentiality of Medical Information Act (CMIA).
7. This Quotation Estimate does not guarantee insurance coverage. The client is advised to verify benefits, pre-authorization requirements, and any prior-authorization mandates directly with their insurance provider before commencing Occupational Therapist services.
8. Disputes arising from this Quotation Estimate or the subsequent provision of Occupational Therapy services shall be governed by the laws of the State of California and the United States of America, with jurisdiction in the Superior Court of Los Angeles County.

6. Acceptance and Authorization

By signing below, the client or authorized representative acknowledges receipt of this Quotation Estimate for Occupational Therapist services in the United States Los Angeles area and agrees to the terms and conditions outlined herein. This signature does not constitute a guarantee of insurance payment but represents the client's acceptance of the estimated cost structure and service plan.