Quotation Estimate Physiotherapist in United States Houston –Free Word Template Download with AI

Client Information

Scope of Physiotherapist Services

This Quotation Estimate has been prepared by our licensed Physiotherapist team at Houston Physiotherapy & Rehabilitation Center, located in the heart of United States Houston. The following services are recommended based on the initial clinical assessment conducted on June 5, 2025, for the treatment of a Grade II lumbar disc herniation (L4-L5) with associated radiculopathy. The Physiotherapist assigned to this case, Dr. Elena Vasquez, DPT, OCS, will oversee the full course of rehabilitation. All services are delivered in compliance with Texas State Board of Physical Therapy Examiners regulations and applicable federal healthcare standards within the United States Houston metropolitan area.

Itemized Quotation Estimate Breakdown

Estimated Insurance Coverage Note

Based on preliminary verification with Blue Cross Blue Shield of Texas, the client's policy is expected to cover approximately 80% of the total Quotation Estimate after the annual deductible of $1,500 has been met. The client is responsible for the remaining 20% co-payment and any applicable copay per visit. Our billing department in United States Houston will submit all claims electronically on behalf of the client. The final out-of-pocket amount may vary depending on the specific plan terms and any pre-authorization requirements. The Physiotherapist team will provide itemized receipts for every session to facilitate insurance reimbursement.

Terms and Conditions of This Quotation Estimate

1. This Quotation Estimate is valid for thirty (30) days from the date of issue. After the expiration date, pricing may be subject to revision based on current fee schedules in United States Houston.
2. All Physiotherapist services listed herein require a valid referral or prescription from a licensed physician, orthopedic specialist, or sports medicine doctor as mandated by Texas Health and Safety Code, Chapter 458.
3. The total program duration is estimated at twelve (12) weeks. The lead Physiotherapist reserves the right to extend or modify the treatment plan based on the client's clinical progress and response to therapy.
4. Cancellations must be made at least twenty-four (24) hours in advance. Late cancellations or no-shows will be charged at 50% of the session fee.
5. Payment is due within fifteen (15) days of the final invoice. A 1.5% monthly late fee will be applied to outstanding balances. Accepted payment methods include credit/debit cards, ACH bank transfer, and HSA/FSA cards.
6. All client health information is protected under the Health Insurance Portability and Accountability Act (HIPAA) and Texas Medical Records Privacy Act. No information will be disclosed without written consent.
7. This Quotation Estimate does not constitute a guarantee of specific medical outcomes. The Physiotherapist team will use best clinical judgment and evidence-based practices throughout the treatment course.
8. Any additional services not listed in this Quotation Estimate (e.g., imaging referrals, surgical consultation, additional orthotics) will be quoted separately and require prior written approval from the client.
9. By signing below, the client acknowledges receipt and understanding of this Quotation Estimate and agrees to the terms outlined above.

Acceptance and Authorization