Invoice Psychologist in United States Miami –Free Word Template Download with AI
Licensed Clinical Psychologists
1200 Brickell Avenue, Suite 450
Miami, FL 33131, United States
Phone: (305) 555-0199 | Email: [email protected]
FL License No: PSY-987654
Invoice Number: INV-2023-10-042
Date Issued: October 24, 2023
Due Date: November 24, 2023
BILL TO:
Mr. Jonathan A. Sterling
4500 Collins Avenue, Apt 12B
Miami Beach, FL 33140
United States
Phone: (305) 555-0882
INSURANCE / REFERRAL INFO:
Provider: Blue Cross Blue Shield of Florida
Policy Holder: Jonathan A. Sterling
Member ID: BCB-9988776655
Group Number: GRP-MIA-202
Referring Physician: Dr. Elena Rodriguez, MD
| Date | Description of Psychological Services | CPT Code | Rate | Amount |
|---|---|---|---|---|
| Oct 02, 2023 |
Initial Comprehensive Psychological Evaluation Conducted by Dr. Sarah Jenkins, Ph.D. This session included a detailed clinical interview, history taking, and administration of standardized diagnostic instruments to assess mood, anxiety levels, and cognitive functioning. |
96132 | $350.00 | $350.00 |
| Oct 09, 2023 |
Individual Psychotherapy Session (45 mins) Cognitive Behavioral Therapy (CBT) focused on stress management and anxiety reduction techniques. Session conducted in-person at our Miami, FL office. |
90834 | $200.00 | $200.00 |
| Oct 16, 2023 |
Individual Psychotherapy Session (45 mins) Continued CBT intervention. Review of coping strategies and behavioral activation exercises. Discussion of progress regarding sleep hygiene and panic disorder management. |
90834 | $200.00 | $200.00 |
| Oct 23, 2023 |
Psychological Testing Scoring and Interpretation Analysis of data from the Beck Depression Inventory-II and the State-Trait Anxiety Inventory. Preparation of preliminary diagnostic impressions for review. |
96136 | $150.00 | $150.00 |
| Oct 23, 2023 |
Telehealth Consultation (15 mins) Brief follow-up consultation regarding medication side effects reported by the patient. Coordination of care with prescribing psychiatrist in Miami-Dade County. |
99441 | $75.00 | $75.00 |
Payment Instructions
Please remit payment for the outstanding balance of $100.00 by the due date listed above. Late payments may be subject to a 1.5% monthly finance charge.
Accepted Methods:
- Check: Payable to "Miami Coastal Psychology Group". Mail to the address listed in the header.
- Credit Card: Visa, MasterCard, and American Express accepted via our secure online portal at portal.miamicoastalpsych.com.
- Wire Transfer: Bank of America, Miami Branch. Routing: 026009593, Account: 1234567890.
Note: As a licensed Psychologist operating in the State of Florida, all financial records are maintained in accordance with HIPAA regulations and Florida Statutes Chapter 490.
Terms and Conditions of Service
- Confidentiality: All information contained in this invoice and related to the psychological services provided is protected under the Health Insurance Portability and Accountability Act (HIPAA). This document is 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 of the scheduled appointment time.
- Insurance Verification: While we strive to verify benefits prior to treatment, the patient is ultimately responsible for any co-pays, deductibles, or non-covered services as determined by their insurance provider.
- Jurisdiction: This agreement and invoice are governed by the laws of the State of Florida. Any disputes arising from these services shall be resolved in the courts of Miami-Dade County.
Authorized By:
Dr. Sarah Jenkins, Ph.D.
Licensed Psychologist
Miami Coastal Psychology Group
Patient Acknowledgement:
Signature:
Date:
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