Invoice Psychiatrist in United States New York City –Free Word Template Download with AI
450 Park Avenue, Suite 1205
New York, NY 10022
United States
Phone: (212) 555-0198
Fax: (212) 555-0199
Email: [email protected]
NPI: 1234567890
NY State License: PSY-1234567 Bill To (Patient) Mr. Jonathan A. Sterling
15 West 72nd Street, Apt 4B
New York, NY 10023
United States
DOB: 05/12/1985
Patient ID: JS-8842 Insurance Information Empire Blue Cross Blue Shield
Group #: EBC-998877
Policy #: 4455-6677-8899
Subscriber: Jonathan A. Sterling
Relationship: Self
| Date of Service | CPT Code | Description of Psychiatry Services | ICD-10 Dx | Charges | Patient Responsibility |
|---|---|---|---|---|---|
| Oct 02, 2023 | 90837 | Psychiatric diagnostic evaluation and psychotherapy, 60 minutes. Comprehensive assessment of mood symptoms and medication history in New York City clinic. | F32.1 | $350.00 | $75.00 |
| Oct 09, 2023 | 90837 | Individual psychotherapy session, 60 minutes. Focus on cognitive behavioral strategies for anxiety management and medication adherence review. | F41.1 | $350.00 | $75.00 |
| Oct 16, 2023 | 90837 | Individual psychotherapy session, 60 minutes. Continued treatment plan implementation and monitoring of side effects from recent pharmacological adjustments. | F32.1 | $350.00 | $75.00 |
| Oct 23, 2023 | 90837 | Individual psychotherapy session, 60 minutes. Review of progress, adjustment of therapeutic goals, and preparation for upcoming follow-up evaluation. | F41.1 | $350.00 | $75.00 |
| Oct 16, 2023 | 90847 | Family psychotherapy session, 60 minutes. Session conducted with patient and spouse to discuss support systems and communication strategies. | F32.1 | $450.00 | $100.00 |
Payment Terms and Important Information
This invoice represents the balance due for psychiatric services rendered by Dr. Eleanor Vance, MD, at the Manhattan Center for Mental Health in New York City. As per our agreement and standard practice in the United States healthcare system, the patient is responsible for any co-pays, deductibles, and non-covered services as determined by their insurance provider.
Payment Methods: We accept Visa, MasterCard, American Express, Discover, and personal checks payable to "Dr. Eleanor Vance, MD." Online payments can be made securely via our patient portal at patientportal.drvancepsychiatry.com.
Due Date: Payment is due within 30 days of the invoice date. Late payments may be subject to a 1.5% monthly finance charge. Please make checks payable to Dr. Eleanor Vance, MD, and mail to the address listed in the header of this invoice.
Insurance Claims: If you believe there is an error regarding the insurance adjustment or payment, please contact our billing department immediately with your Explanation of Benefits (EOB) from your insurance carrier. We are committed to resolving any discrepancies promptly.
Privacy Notice: In accordance with HIPAA regulations and New York State privacy laws, your medical and billing information is kept strictly confidential. This invoice contains protected health information (PHI) and should be handled securely.
Cancellation Policy: Please note that our office requires 24 hours' notice for appointment cancellations. Failure to provide notice may result in a cancellation fee, which will be billed separately.
Thank you for trusting Dr. Vance with your mental health care. We appreciate your prompt payment and continued partnership in your wellness journey.
Authorized SignatureDr. Eleanor Vance, MD Patient Signature (Acknowledgement)
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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