Invoice Psychiatrist in United States Houston –Free Word Template Download with AI

Bill To: Mr. James A. Sterling
4500 Westheimer Road, Apt 12B
Houston, Texas 77027
United States
Phone: (281) 555-0144 Invoice Details: Invoice Number: INV-HOU-2023-8942
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Period: October 1, 2023 - October 20, 2023
Insurance: Blue Cross Blue Shield of Texas (ID: BCBS-TX-998877)

Dear Mr. Sterling,

This document serves as an official Invoice for psychiatric medical services rendered by Dr. Elena Rostova at our clinic located in United States Houston. As a leading provider of mental health care in the Greater Houston area, we are committed to providing transparent billing practices that comply with Texas state regulations and federal healthcare standards.

The following charges reflect the professional fees associated with your recent consultations, diagnostic evaluations, and therapeutic interventions. These services were provided in accordance with the standards of care expected of a licensed Psychiatrist practicing within the United States. Please review the line items below carefully.

Date of Service	Description of Service	CPT Code	ICD-10 Code	Fee
Oct 02, 2023	Initial psychiatric diagnostic evaluation (60 mins). Comprehensive assessment of mental status, history, and formulation of treatment plan.	90792	F41.1	$350.00
Oct 09, 2023	Psychiatric diagnostic evaluation (45 mins). Follow-up assessment to monitor medication efficacy and adjust dosage protocols.	90791	F41.1	$275.00
Oct 16, 2023	Psychiatric collaborative care management services. Coordination with primary care physician in Houston regarding comorbid conditions.	99492	Z79.899	$150.00
Oct 20, 2023	Psychiatric medication management (30 mins). Review of side effects, adherence counseling, and prescription renewal.	90834	F41.1	$200.00

Subtotal: $975.00 Insurance Adjustment (BCBS): -$425.00 Insurance Payment Applied: -$350.00 Texas State Sales Tax (N/A for Medical): $0.00 Patient Responsibility (Due): $200.00

Important Billing Information & Terms

Payment Methods: We accept major credit cards (Visa, MasterCard, Amex), checks payable to "Houston Behavioral Health Associates," and direct bank transfers. Online payments can be made securely via our patient portal.

Insurance Verification: This Invoice reflects the balance remaining after your insurance provider, Blue Cross Blue Shield of Texas, has processed their portion of the claim. As a Psychiatrist operating in United States Houston, we participate in-network with major carriers to minimize out-of-pocket expenses for our patients. However, copays and deductibles are the responsibility of the patient.

Disputes: If you believe there is an error on this invoice, please contact our billing department within 14 days of the invoice date. We are dedicated to resolving any discrepancies promptly and professionally.

Confidentiality: In compliance with HIPAA regulations, this document contains protected health information. Please handle it with care and do not share it with unauthorized individuals.

Thank You: Thank you for trusting Dr. Rostova and our team with your mental health care. We look forward to continuing our work together to support your well-being.

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