Invoice Psychologist in United States Houston –Free Word Template Download with AI
Licensed Psychologist (License #PSY-48291)
Center for Cognitive Behavioral Health
1200 Main Street, Suite 405
Houston, Texas 77002
United States
Phone: (713) 555-0198 | Email: [email protected]
Invoice #: INV-2023-10-042
Date: October 24, 2023
Due Date: November 24, 2023
Reference: Insurance Claim / Self-Pay
Bill To:
Mr. James A. Sterling
3400 Westheimer Road, Apt 12B
Houston, Texas 77027
United States
Phone: (281) 555-0142
Insurance Provider: Blue Cross Blue Shield of Texas
Policy Number: TX-9988776655
Group Number: GRP-HOU-5543
| Date | Description of Psychological Services | CPT Code | Unit Price | Total |
|---|---|---|---|---|
| Oct 02, 2023 |
Initial Psychological Evaluation Comprehensive clinical interview and diagnostic assessment conducted in Houston, TX. Includes history taking, symptom analysis, and formulation of treatment plan. |
96116 | $350.00 | $350.00 |
| Oct 09, 2023 |
Individual Psychotherapy Session 45-minute session focusing on Cognitive Behavioral Therapy (CBT) techniques for anxiety management. |
90834 | $175.00 | $175.00 |
| Oct 16, 2023 |
Individual Psychotherapy Session 45-minute session focusing on stress reduction strategies and coping mechanisms. |
90834 | $175.00 | $175.00 |
| Oct 23, 2023 |
Psychological Testing Administration Administration of standardized psychological tests (Beck Depression Inventory, GAD-7) to monitor progress. |
96136 | $120.00 | $120.00 |
| Subtotal: | $820.00 |
| Tax (0% - Medical Exempt): | $0.00 |
| Insurance Adjustment (Est.): | -$220.00 |
| Total Amount Due: | $600.00 |
Terms and Conditions / Important Notes:
- Payment Terms: Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge.
- Insurance Billing: This invoice is submitted to the insurance provider listed above. The patient is responsible for any co-pays, deductibles, or non-covered services as per their policy terms.
- Confidentiality: In accordance with HIPAA regulations and Texas state laws, all patient information contained in this invoice is confidential and intended solely for the use of the individual or entity to whom it is addressed.
- Cancellation Policy: A fee of 50% of the session rate applies for cancellations made less than 24 hours in advance.
- Provider Credentials: Dr. Elena R. Vance is a licensed Psychologist practicing in Houston, Texas, adhering to the ethical standards of the American Psychological Association (APA).
- Disputes: Any disputes regarding this invoice must be raised in writing within 14 days of receipt.
Payment Methods: Checks payable to "Dr. Elena R. Vance, Ph.D." may be mailed to the address above. Credit card payments can be processed securely via our patient portal.
Authorized Signature:
Dr. Elena R. Vance, Ph.D.
Principal Psychologist
Patient Acknowledgement:
__________________________
Date: _______________
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