Quotation Estimate Physiotherapist in United States New York City –Free Word Template Download with AI

Quotation Estimate

Quotation Details

Quotation Estimate No.: QTE-2025-04872

Date of Issue: June 12, 2025

Valid Until: July 12, 2025

Prepared By: Dr. Elena Vasquez, DPT, OCS

Service Location: United States New York City

Client Information

Client Name: Mr. Jonathan R. Whitfield

Address: 88 Park Avenue South, Apt 14B, New York, NY 10016

Phone: (917) 555-0342

Email: [email protected]

Insurance Provider: Aetna PPO – Member ID: AET-7729104

Dear Mr. Whitfield,

Thank you for contacting Manhattan Physiotherapy & Rehabilitation Center regarding your post-operative rehabilitation needs. This Quotation Estimate has been prepared by our senior Physiotherapist, Dr. Elena Vasquez, following your initial consultation on June 5, 2025, at our clinic located in the heart of United States New York City. The purpose of this document is to provide you with a comprehensive, itemized breakdown of the anticipated costs for your full course of physiotherapy treatment. Please review this Quotation Estimate carefully and do not hesitate to reach out should you require clarification on any line item or service description.

Based on the clinical assessment conducted by our licensed Physiotherapist, the following treatment plan has been designed to address your right total knee replacement recovery. The program spans approximately twelve (12) weeks and includes a combination of manual therapy, therapeutic exercise, electrotherapy, and functional mobility training. All services are delivered by a board-certified Physiotherapist in compliance with New York State Department of Health regulations and the standards set forth by the American Physical Therapy Association.

Item #	Service Description	Frequency	Duration	Unit Rate (USD)	Estimated Total (USD)
01	Initial Comprehensive Physiotherapist Assessment & Treatment Plan Development	One-time	60 min	$220.00	$220.00
02	Manual Therapy & Joint Mobilization (Knee Focus)	3x / week	45 min	$185.00	$2,590.00
03	Therapeutic Exercise & Strengthening Program	3x / week	45 min	$175.00	$2,450.00
04	Electrotherapy (TENS, Ultrasound, Iontophoresis)	2x / week	30 min	$140.00	$1,120.00
05	Functional Mobility & Gait Retraining	2x / week	40 min	$165.00	$1,320.00
06	Progressive Range-of-Motion & Flexibility Sessions	2x / week	30 min	$130.00	$1,040.00
07	Mid-Program Re-Assessment by Lead Physiotherapist	One-time (Week 6)	45 min	$195.00	$195.00
08	Final Discharge Assessment & Home Exercise Program	One-time (Week 12)	60 min	$210.00	$210.00
09	Custom Orthotic / Bracing Consultation & Fitting	One-time	30 min	$150.00	$150.00
10	Telehealth Follow-Up Check-In (Post-Discharge)	2 sessions	20 min each	$85.00	$170.00
SUBTOTAL (All Physiotherapist Services)					$9,465.00
Estimated Insurance Coverage (Aetna PPO – 80%)					-$7,572.00
ESTIMATED PATIENT RESPONSIBILITY					$1,893.00

This Quotation Estimate is based on the current fee schedule of our Physiotherapist practice as of June 2025 and reflects standard rates for outpatient physiotherapy services in the United States New York City metropolitan area. The estimated insurance coverage amount is a projection based on your Aetna PPO plan benefits and is subject to verification by our billing department. Actual reimbursement may vary depending on your plan's deductible status, out-of-pocket maximums, and any pre-authorization requirements. This Quotation Estimate does not constitute a binding contract; final charges will be determined upon completion of the treatment course. All rates are subject to annual adjustment in accordance with New York State fee guidelines.

1. This Quotation Estimate is valid for thirty (30) days from the date of issue. After the expiration date, rates may be subject to revision based on current United States New York City market conditions.
2. All physiotherapy services must be performed by a licensed Physiotherapist holding an active New York State Professional License. Our practice maintains full compliance with NYS Education Department and NYS Department of Health regulations.
3. A 24-hour cancellation notice is required for all scheduled appointments. Late cancellations or no-shows will be charged at 50% of the session fee.
4. The client is responsible for any co-pays, deductibles, or coinsurance amounts not covered by the insurance provider. Our billing team will provide itemized statements following each billing cycle.
5. This Quotation Estimate assumes a standard twelve-week treatment protocol. If the treating Physiotherapist determines that additional sessions are clinically necessary, a supplementary Quotation Estimate will be issued and approved by the client prior to additional services being rendered.
6. All patient records and treatment data are maintained in strict accordance with HIPAA (Health Insurance Portability and Accountability Act) regulations and New York State public health law.
7. This Quotation Estimate is prepared exclusively for the named client and may not be transferred to a third party without written consent from Manhattan Physiotherapy & Rehabilitation Center.
8. In the event of a dispute regarding charges, the client agrees to first contact our billing office. Unresolved disputes will be handled in accordance with New York State consumer protection statutes applicable to healthcare services in the United States New York City jurisdiction.

By signing below, the client acknowledges receipt of this Quotation Estimate and authorizes Manhattan Physiotherapy & Rehabilitation Center to proceed with the outlined Physiotherapist treatment plan. The client confirms that all information provided in this document has been reviewed and understood.

Client Signature
Jonathan R. Whitfield
Date: ______________________ Physiotherapist / Authorized Representative
Dr. Elena Vasquez, DPT, OCS
Date: ______________________ ⬇️ Download as DOCX Edit online as DOCX

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