Invoice Psychiatrist in United States Los Angeles –Free Word Template Download with AI
1200 Wilshire Blvd, Suite 400
Los Angeles, CA 90017
United States
Phone: (213) 555-0198
Email: [email protected]
NPI: 1234567890 | CA License: A123456
INVOICE
Invoice #: INV-2023-10-042
Date Issued: October 24, 2023
Due Date: November 24, 2023
Service Period: October 1, 2023 - October 23, 2023
Bill To (Insurance / Guarantor)
Blue Cross Blue Shield of California
P.O. Box 99999
Los Angeles, CA 90095
United States
Group ID: BCBS-LA-998877
Policyholder: John Doe
Name: Jane Doe
Date of Birth: 05/12/1985
Member ID: 987654321
Address: 456 Sunset Blvd, Los Angeles, CA 90028
| Date of Service | Description of Psychiatry Services | CPT Code | ICD-10 Dx | Qty | Rate | Amount |
|---|---|---|---|---|---|---|
| Oct 02, 2023 | Initial psychiatric diagnostic evaluation of new patient; 60 minutes. Comprehensive assessment conducted in Los Angeles clinic. | 90792 | F41.1 | 1 | $350.00 | $350.00 |
| Oct 09, 2023 | Psychiatric diagnostic evaluation of an established patient; 30 minutes. Medication management and follow-up. | 90791 | F41.1 | 1 | $225.00 | $225.00 |
| Oct 16, 2023 | Psychiatric diagnostic evaluation of an established patient; 45 minutes. Complex medication management. | 90792 | F41.1 | 1 | $350.00 | $350.00 |
| Oct 23, 2023 | Psychiatric collaborative care management services; per 1,000 patients enrolled. | 99492 | Z00.00 | 1 | $150.00 | $150.00 |
Payment Terms and Important Information
This invoice represents professional psychiatric services rendered by Dr. Elena Rostova in Los Angeles, California. Please note that amounts listed are estimates based on current fee schedules. Final patient responsibility may vary depending on the Explanation of Benefits (EOB) provided by your insurance carrier.
Payment Methods: We accept Visa, MasterCard, American Express, Discover, and checks payable to "Rostova Psychiatry Group." Online payments can be made securely via our patient portal.
Late Fees: Accounts unpaid after 30 days from the due date may be subject to a late fee of 1.5% per month or the maximum allowed by California law, whichever is less.
Disputes: If you believe there is an error on this invoice, please contact our billing department within 14 days of receipt. Please reference Invoice #INV-2023-10-042 in all correspondence.
Privacy Notice: In accordance with HIPAA regulations, your protected health information is kept strictly confidential. This invoice contains limited health information necessary for billing purposes.
Authorized SignatureDr. Elena Rostova, MD
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