Invoice Psychologist in United States Chicago –Free Word Template Download with AI
Chicago Center for Cognitive Health
123 N. Michigan Avenue, Suite 400
Chicago, IL 60601, United States
Phone: (312) 555-0199
Email: [email protected]
License No.: PSY-12345678 (State of Illinois)
NPI: 1234567890
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:
Mr. Jonathan A. Sterling
456 W. Fullerton Parkway
Chicago, IL 60614, United States
Phone: (773) 555-0123
Email: [email protected]
Insurance Information (If Applicable):
Provider: Blue Cross Blue Shield of Illinois
Policy Number: BCBS-99887766
Group Number: GRP-554433
Subscriber ID: JS-12345
| Date | CPT Code | Description of Psychological Services | Quantity | Amount (USD) |
|---|---|---|---|---|
| Oct 02, 2023 | 90791 | Psychological Evaluation (Initial): Comprehensive cognitive and emotional assessment including history taking and standardized testing administration. | 1 | $450.00 |
| Oct 05, 2023 | 90837 | Psychotherapy (45 min): Individual session focusing on anxiety management techniques and cognitive behavioral strategies. | 1 | $225.00 |
| Oct 09, 2023 | 90837 | Psychotherapy (45 min): Individual session addressing workplace stressors and interpersonal dynamics. | 1 | $225.00 |
| Oct 12, 2023 | 90792 | Psychological Evaluation (Follow-up): Scoring and interpretation of assessment data, formulation of diagnostic impressions. | 1 | $350.00 |
| Oct 16, 2023 | 90837 | Psychotherapy (45 min): Individual session reviewing evaluation results and establishing treatment goals. | 1 | $225.00 |
| Oct 19, 2023 | 90837 | Psychotherapy (45 min): Individual session implementing coping mechanisms and mindfulness exercises. | 1 | $225.00 |
| Oct 23, 2023 | 90837 | Psychotherapy (45 min): Individual session focusing on relapse prevention planning and progress monitoring. | 1 | $225.00 |
Payment Instructions:
Please remit payment within 30 days of the invoice date. Late payments may be subject to a 1.5% monthly interest charge in accordance with Illinois state regulations.
Accepted Payment Methods:
- Check: Payable to "Dr. Elena Rostova, Psy.D." and mailed to the address listed above.
- Credit Card: Visa, MasterCard, and American Express accepted via our secure online portal.
- ACH Transfer: Bank details available upon request.
Online Payment: Visit www.chicagocognitivehealth.com/pay and enter Invoice # INV-2023-10-042.
Important Notes Regarding Psychological Services:
This invoice represents professional psychological services rendered in the State of Illinois. All services were provided in accordance with the ethical guidelines of the American Psychological Association (APA) and the laws governing the practice of psychology in the United States.
Please note that this invoice is for billing purposes only and does not constitute a medical record. Detailed clinical notes are maintained securely in our electronic health record system and are accessible only to authorized personnel.
If you have any questions regarding the charges, CPT codes, or the services provided, please contact our billing department at (312) 555-0199. We are committed to ensuring transparency and clarity in all financial matters related to your care.
Confidentiality: In compliance with HIPAA regulations, all patient information contained in this invoice is confidential and should not be shared with unauthorized parties.
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