Quotation Estimate Psychiatrist in United States Houston –Free Word Template Download with AI
Professional Psychiatrist Services — Houston, Texas, United States
Quotation Estimate No. QE-HOU-2025-04782
Provider Information
Dr. Margaret A. Whitfield, M.D., Ph.D.
Board-Certified Psychiatrist
Whitfield Behavioral Health Associates
4820 Westheimer Road, Suite 310
Houston, Texas 77056, United States
Tel: (713) 555-0142
Email: [email protected]
Texas Medical License: TX-PSY-2019-88431
Client / Requesting Party
Client Name: [To be completed]
Organization: [To be completed]
Address: Houston, Texas, United States
Contact Phone: [To be completed]
Email: [To be completed]
Insurance Provider: [To be completed]
Policy / Member ID: [To be completed]
Quotation Details
Date of Issue: June 12, 2025
Valid Until: July 12, 2025 (30 days)
Service Location: Houston, Texas, United States
Payment Terms: Net 30 / Insurance Billing
Referral / Authorization
Referring Physician: [To be completed]
Pre-Authorization No.: [To be completed]
Reason for Referral: Comprehensive psychiatric evaluation and ongoing treatment planning
This Quotation Estimate outlines the anticipated costs for a full course of Psychiatrist services to be rendered in Houston, United States. The services described below are provided by Dr. Margaret A. Whitfield, a board-certified Psychiatrist with over fifteen years of clinical experience in adult and geriatric psychiatry. All consultations, diagnostic evaluations, and therapeutic interventions will take place at the Whitfield Behavioral Health Associates clinic located in the Westchase medical district of Houston, Texas. This Quotation Estimate is intended to give the client a transparent and detailed financial projection for the recommended course of psychiatric care.
| # | Service Description | CPT Code | Qty | Unit Price (USD) | Estimated Total (USD) |
|---|---|---|---|---|---|
| 1 | Initial Comprehensive Psychiatric Evaluation (90-minute session including medical history, mental status examination, and diagnostic assessment) | 99205 | 1 | $425.00 | $425.00 |
| 2 | Follow-up Psychiatric Consultation (45-minute session for treatment plan review and medication management) | 99214 | 6 | $285.00 | $1,710.00 |
| 3 | Psychological Testing and Neuropsychiatric Assessment (battery of standardized instruments administered and interpreted by the Psychiatrist) | 96132 | 1 | $650.00 | $650.00 |
| 4 | Psychiatric Medication Management and Prescription Renewal (includes lab work coordination with local Houston laboratories) | 99213 | 4 | $195.00 | $780.00 |
| 5 | Family / Caregiver Psychoeducation Session (60-minute session for up to four family members) | 90837 | 2 | $310.00 | $620.00 |
| 6 | Psychiatric Consultation Note and Treatment Summary Report (written documentation for referring physician or employer) | 99241 | 2 | $150.00 | $300.00 |
| 7 | Telepsychiatry Video Consultation (for clients unable to travel to the Houston office; HIPAA-compliant platform) | 99441 | 2 | $220.00 | $440.00 |
| 8 | Urgent / After-Hours Psychiatric Crisis Consultation (phone or in-person, Houston metropolitan area) | 99215 | 1 | $375.00 | $375.00 |
| ESTIMATED GRAND TOTAL (Before Insurance Adjustment): | $5,300.00 | ||||
- This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. After the expiration date, all fees are subject to revision in accordance with the current fee schedule of the Psychiatrist's practice in Houston, United States.
- All services described herein will be performed by Dr. Margaret A. Whitfield or, in her absence, by a credentialed Psychiatrist of equivalent training and board certification within the same Houston practice.
- Payment is due within thirty (30) days of the date of service. For insurance-covered services, the client is responsible for any applicable copayments, deductibles, or non-covered charges at the time of the visit.
- Cancellations or rescheduling of appointments must be made at least twenty-four (24) hours in advance. Late cancellations or no-shows will be subject to a fee of fifty percent (50%) of the scheduled session rate.
- All patient records, psychiatric notes, and diagnostic reports are protected under the Health Insurance Portability and Accountability Act (HIPAA) and applicable Texas state privacy laws. No information will be disclosed without written patient consent except as required by law.
- This Quotation Estimate does not constitute a guarantee of specific psychiatric outcomes. Treatment plans will be individualized and may be modified by the Psychiatrist based on clinical judgment during the course of care in Houston.
- Any services not explicitly listed in this Quotation Estimate (e.g., inpatient psychiatric admission, additional psychological testing, or referral to a Houston-based substance abuse specialist) will be quoted separately in writing prior to rendering.
- This Quotation Estimate is non-transferable and is issued solely for the client identified above. It does not obligate the provider to render services until a formal treatment agreement or insurance pre-authorization is executed.
By signing below, the client acknowledges receipt of this Quotation Estimate for Psychiatrist services in Houston, United States, and agrees to the terms and conditions outlined above. The client further confirms that they have had the opportunity to ask questions regarding the scope, cost, and expected duration of the psychiatric treatment plan.
Client SignatureName / Date Authorized Representative (if applicable)
Name / Title / Date Provider — Dr. M.A. Whitfield, M.D.
Psychiatrist / Date ⬇️ Download as DOCX Edit online as DOCX
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