Invoice Psychologist in United States San Francisco –Free Word Template Download with AI
Licensed Clinical Psychologist Services
1234 Market Street, Suite 500
San Francisco, CA 94103
Phone: (415) 555-0199 | Email: [email protected]
#INV-2023-10-042
Date: October 24, 2023
Due Date: November 24, 2023
From Dr. Elena Rodriguez, Ph.D.Licensed Psychologist (PSY 28491)
State of California Board of Psychology
NPI: 1234567890
Tax ID: XX-XXXXXXX Bill To Johnathan Doe
567 Valencia Street
San Francisco, CA 94110
United States
Insurance: Blue Shield of California
Member ID: BS-99887766
| Description of Services | Date of Service | CPT Code | Units | Amount (USD) |
|---|---|---|---|---|
|
Individual Psychotherapy Session One-on-one clinical session conducted in-person at our San Francisco office. Focus included cognitive-behavioral strategies for anxiety management and stress reduction techniques tailored to the client's specific needs. |
Oct 02, 2023 | 90837 | 1 | $225.00 |
|
Psychological Evaluation & Assessment Comprehensive diagnostic assessment including clinical interview and standardized testing (WAIS-IV, MMPI-3). This service is critical for establishing a baseline for treatment planning and is performed by a licensed Psychologist in accordance with California state regulations. |
Oct 10, 2023 | 96130 | 1 | $450.00 |
|
Individual Psychotherapy Session Follow-up session discussing assessment results and integrating findings into the ongoing therapeutic plan. Session included psychoeducation regarding emotional regulation. |
Oct 17, 2023 | 90837 | 1 | $225.00 |
|
Collateral Contact / Consultation Telephone consultation with referring physician to coordinate care and discuss treatment recommendations. This ensures a holistic approach to mental health care within the San Francisco healthcare network. |
Oct 20, 2023 | 99488 | 1 | $150.00 |
| Subtotal | $1,050.00 |
| Insurance Adjustment (Est.) | -$350.00 |
| Insurance Payment Received | -$400.00 |
| Balance Due | $300.00 |
Payment Terms & Important Information
This Invoice represents the professional fees for psychological services rendered by a licensed Psychologist in the state of California. Payment is due within 30 days of the invoice date. Please make checks payable to "Mindful Bay Area Psychology" or utilize our secure online payment portal.
Insurance Billing: We have submitted the claims associated with this Invoice to your insurance provider. The amounts listed above reflect the contractual adjustments and payments received to date. You are responsible for any co-pays, deductibles, or non-covered services as outlined in your insurance policy.
Confidentiality: In accordance with HIPAA regulations and California state law, the information contained in this Invoice is confidential. Please handle this document securely. If you have any questions regarding the services provided or the billing details, please contact our billing department directly.
Location Note: All in-person services were conducted at our licensed facility in San Francisco, United States. Telehealth services, if applicable, are billed at the same rate and are compliant with California telehealth regulations.
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