Invoice Psychologist in United States New York City –Free Word Template Download with AI
Licensed Clinical Psychologist (License #PSY-0048291)
Manhattan Center for Cognitive & Behavioral Health
450 Park Avenue South, Suite 712
New York, NY 10016
United States
Phone: (212) 555-0198 | Email: [email protected]
Invoice Number: 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
128 West 72nd Street, Apt 4B
New York, NY 10023
United States
Patient ID: PAT-882910
Insurance / Payer Information:
Empire Blue Cross Blue Shield
Policyholder: Jonathan A. Sterling
Member ID: EBC-992810-XJ
Group Number: NY-MET-4402
Provider ID: 10048291
| # | Date of Service | Description of Psychological Services | CPT Code | ICD-10 Code | Quantity | Rate | Amount |
|---|---|---|---|---|---|---|---|
| 1 | Oct 02, 2023 | Individual Psychotherapy Session (45 mins). Focus on cognitive restructuring and anxiety management techniques within the context of urban stressors. | 90837 | F41.1 | 1 | $250.00 | $250.00 |
| 2 | Oct 09, 2023 | Individual Psychotherapy Session (45 mins). Continued behavioral activation strategies and mood monitoring review. | 90837 | F41.1 | 1 | $250.00 | $250.00 |
| 3 | Oct 16, 2023 | Individual Psychotherapy Session (45 mins). Exploration of interpersonal dynamics and coping mechanisms for workplace conflict. | 90837 | F41.1 | 1 | $250.00 | $250.00 |
| 4 | Oct 23, 2023 | Psychological Evaluation Report Compilation. Comprehensive review of clinical interview data, standardized testing results, and diagnostic formulation. | 96132 | Z02.89 | 1 | $850.00 | $850.00 |
Important Payment & Service Information
Payment Methods: This invoice may be paid via check payable to "Dr. Elena Rostova, PhD", via credit card (Visa, MasterCard, Amex), or via bank transfer. For bank transfers, please reference Invoice Number INV-2023-10-042 in the memo line.
Insurance Claims: As a licensed Psychologist practicing in New York City, this document serves as a formal request for reimbursement from your insurance provider. Please submit this invoice along with your Explanation of Benefits (EOB) if you have not already done so. Note that pre-authorization was obtained for the psychological evaluation (CPT 96132).
Late Fees: In accordance with New York State regulations and our office policy, a late fee of 1.5% per month will be applied to any outstanding balance after the due date of November 24, 2023.
Confidentiality: This invoice contains protected health information (PHI) under HIPAA regulations. Please handle this document with care and dispose of it securely once payment is processed.
Contact: If you have any questions regarding this invoice, the services rendered, or your insurance coverage, please contact our billing department at (212) 555-0198 or email [email protected]. We are committed to ensuring clarity and transparency in all financial matters related to your mental health care.
Authorized Signature:
Elena Rostova
Dr. Elena Rostova, PhD
Licensed Clinical Psychologist
Patient Acknowledgement:
By signing below, I acknowledge receipt of this invoice and agree to the terms of payment outlined above.
__________________________
Date: _________________
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