Invoice Psychologist in United States Los Angeles –Free Word Template Download with AI
Board-Certified Clinical Psychologist
License Number: PSY 29481
1200 Wilshire Boulevard, Suite 405
Los Angeles, CA 90017
United States
Phone: (213) 555-0198
Email: [email protected]
Payment Request for Professional Services
Bill To:
Mr. Jonathan Sterling
4500 Sunset Boulevard, Apt 12B
Los Angeles, CA 90027
United States
Insurance Provider: Blue Shield of California
Member ID: BS-99887766
Group Number: 445566
| Date of Service | CPT Code | Description of Psychological Services | Rate | Amount |
|---|---|---|---|---|
| Oct 02, 2023 | 90837 | Individual Psychotherapy Session (45-53 mins). Focus on cognitive behavioral strategies for anxiety management and stress reduction techniques tailored for high-performance environments. | $225.00 | $225.00 |
| Oct 09, 2023 | 90837 | Individual Psychotherapy Session (45-53 mins). Continued work on emotional regulation, processing recent interpersonal conflicts, and reinforcing coping mechanisms discussed in previous sessions. | $225.00 | $225.00 |
| Oct 16, 2023 | 90837 | Individual Psychotherapy Session (45-53 mins). Review of progress, adjustment of therapeutic goals, and exploration of underlying patterns contributing to current stressors. | $225.00 | $225.00 |
| Oct 21, 2023 | 90847 | Family Psychotherapy Session (54-80 mins). Joint session with partner to address communication dynamics, establish healthy boundaries, and improve relational support systems. | $300.00 | $300.00 |
Important Information Regarding This Invoice
Payment Terms: Payment is due within 30 days of the invoice date. Please make checks payable to "Dr. Elena Rostova, Psy.D." or utilize the secure online payment portal linked in the email accompanying this document. Late payments may be subject to a 1.5% monthly finance charge.
Insurance Claims: This invoice reflects the standard fee schedule for psychological services provided in Los Angeles, California. While we have submitted claims to your insurance provider, please note that insurance coverage varies by plan. You are ultimately responsible for any balance not covered by your insurance, including deductibles, co-pays, and non-covered services. If you have questions regarding your benefits, please contact your insurance provider directly.
Cancellation Policy: As per our office policy, appointments cancelled or missed without at least 24 hours' notice are subject to a cancellation fee of $150.00. This fee ensures that the Psychologist's time is respected and allows for scheduling flexibility for other clients in need of care.
Confidentiality: All information contained within this invoice and the associated treatment records is protected under the Health Insurance Portability and Accountability Act (HIPAA) and California state privacy laws. This document is intended solely for the use of the individual or entity to whom it is addressed.
Questions? If you have any questions regarding this invoice, the services rendered, or your payment options, please do not hesitate to contact our billing department at (213) 555-0198 or via email. We are committed to providing transparent and professional financial administration alongside our clinical care.
Authorized Signature:Dr. Elena Rostova, Psy.D.
Clinical Director Patient Acknowledgement:
I acknowledge receipt of this invoice and understand my financial responsibility.
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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