Invoice Psychiatrist in United States Chicago –Free Word Template Download with AI
233 S Wacker Drive, Suite 4500
Chicago, IL 60606
United States
Phone: (312) 555-0199
Email: [email protected]
NPI: 1234567890
Date Issued: October 24, 2023
Due Date: November 24, 2023
BILL TO:
Mr. Jonathan A. Miller
1800 N Clark Street, Apt 12B
Chicago, IL 60614
United States
Patient ID: #CM-8842
Insurance: Blue Cross Blue Shield of Illinois
Policy #: BCBS-IL-998877
| Date | CPT Code | Description of Psychiatric Services | Diagnosis (ICD-10) | Amount (USD) |
|---|---|---|---|---|
| Oct 02, 2023 | 90792 | Psychiatric diagnostic evaluation with medical services; 60 minutes. Comprehensive intake assessment conducted in Chicago office. | F32.1 | $350.00 |
| Oct 09, 2023 | 90837 | Psychotherapy, 45 minutes with established patient. Focus on cognitive behavioral strategies for mood regulation. | F32.1 | $225.00 |
| Oct 16, 2023 | 90834 | Psychotherapy, 30 minutes with established patient. Medication management review and follow-up. | F32.1 | $175.00 |
| Oct 20, 2023 | 96127 | Psychological testing (administration and scoring) for neuropsychological screening. | F32.1 | $400.00 |
| Oct 20, 2023 | 96130 | Psychological testing (interpretation and report) for neuropsychological screening. | F32.1 | $450.00 |
Terms and Conditions of Service
This invoice represents the financial statement for psychiatric services rendered by Dr. Elena Rostova, MD, located in Chicago, Illinois. As a provider operating within the United States healthcare system, we adhere to strict billing standards. Please note that this invoice reflects the balance remaining after insurance adjudication.
Payment Terms: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge. We accept payments via major credit cards, HSA/FSA cards, personal checks, or bank transfers.
Privacy Notice: In accordance with HIPAA regulations, your financial and medical information is kept strictly confidential. This document contains Protected Health Information (PHI) and should be handled securely.
Disputes: If you believe there is an error on this invoice, please contact our billing department in Chicago within 14 days of receipt. Please reference Invoice Number INV-CHI-2023-10-042 in all correspondence.
Authorized Signature:
Dr. Elena Rostova, MD
Chief Psychiatrist
Patient Acknowledgement:
Signature:
Date:
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