Quotation Estimate Psychiatrist in United States Los Angeles –Free Word Template Download with AI

Quotation Estimate

Quotation Details

Quotation No.: QTE-2025-04872

Date Issued: June 12, 2025

Valid Until: July 12, 2025

Prepared By: Dr. Margaret Chen, MD, Board-Certified Psychiatrist

Client Information

Client Name: [Client Full Name]

Address: [Client Address], Los Angeles, CA

Insurance Provider: [Insurance Company Name]

Policy / Member ID: [Policy Number]

Dear Valued Client,

Thank you for considering Westside Behavioral Health Associates for your mental health care needs. This Quotation Estimate has been prepared specifically for the psychiatric services to be rendered by our licensed Psychiatrist at our practice located in United States Los Angeles. The following document outlines the scope of services, associated fees, and terms governing this professional engagement. Please review this Quotation Estimate carefully before proceeding with treatment.

The Psychiatrist assigned to your care, Dr. Margaret Chen, MD, is a board-certified psychiatrist with over fifteen years of clinical experience in the diagnosis and treatment of mood disorders, anxiety disorders, psychotic disorders, and substance use disorders. All services described in this Quotation Estimate will be delivered in compliance with the California Medical Board regulations and the standards of practice established by the American Psychiatric Association. The practice operates in the greater Los Angeles metropolitan area, serving patients across the United States Los Angeles region including Downtown LA, West Hollywood, Beverly Hills, and surrounding communities.

Item No.	Service Description	Frequency	Unit Cost (USD)	Estimated Total (USD)
1	Initial Comprehensive Psychiatric Evaluation (90-minute session including medical history, mental status examination, and diagnostic assessment)	One-time	$450.00	$450.00
2	Follow-up Psychiatric Consultation (45-minute session for treatment plan review, medication management, and progress monitoring)	Bi-weekly (2x/month) for 6 months	$275.00	$3,300.00
3	Psychopharmacological Management and Prescription Renewal (includes medication titration, side-effect monitoring, and lab work coordination)	Monthly for 6 months	$150.00	$900.00
4	Psychological Testing and Neuropsychological Assessment (administered by the Psychiatrist or designated neuropsychologist)	One-time	$600.00	$600.00
5	Telepsychiatry Video Consultation (for patients unable to attend in-person visits in the Los Angeles area)	As needed (up to 4 sessions)	$225.00	$900.00
6	Emergency After-Hours Psychiatric Consultation (available 7 days a week within the United States Los Angeles service area)	As needed (up to 2 sessions)	$350.00	$700.00
7	Coordination of Care with Primary Care Physician and Therapist (includes written reports, progress notes, and treatment recommendations)	Monthly for 6 months	$75.00	$450.00
8	Administrative and Record-Keeping Fees (includes HIPAA-compliant documentation, insurance billing, and medical record maintenance)	Flat fee	$100.00	$100.00
Estimated Grand Total (Before Insurance Reimbursement)				$7,400.00

This Quotation Estimate reflects the standard fee schedule of our Psychiatrist practice in United States Los Angeles. If your health insurance plan covers psychiatric services, the actual out-of-pocket cost may be significantly lower. We accept most major insurance providers operating in California, including Blue Shield of California, UnitedHealthcare, Aetna, Cigna, and Kaiser Permanente (for out-of-network referrals). Our billing department will submit all claims on your behalf. The client is responsible for any applicable deductibles, copayments, or coinsurance amounts as determined by the insurance carrier. Payment for the full estimated amount, or the applicable patient responsibility portion, is due within thirty (30) days of the date of service. A 1.5% monthly late fee will be applied to any outstanding balance exceeding the thirty-day window.

This Quotation Estimate is valid for thirty (30) days from the date of issuance. Fees are subject to adjustment based on changes in the scope of psychiatric treatment as determined by the treating Psychiatrist.
All psychiatric services will be conducted in strict accordance with the Health Insurance Portability and Accountability Act (HIPAA) and California Confidentiality of Medical Information Act (CMIA). Patient records will be maintained at our secure facility in Los Angeles, California.
The treating Psychiatrist reserves the right to modify the treatment plan, adjust medication regimens, or refer the patient to additional specialists if clinically indicated. Any such modifications will be communicated in writing and may affect the total cost outlined in this Quotation Estimate.
Cancellation of scheduled appointments must be made at least twenty-four (24) hours in advance. Late cancellations or no-shows will be subject to a fee of 50% of the scheduled session cost.
This Quotation Estimate does not constitute a guarantee of specific treatment outcomes. The Psychiatrist will exercise professional medical judgment in determining the most appropriate course of care for each individual patient.
Services rendered outside the standard operating hours of the Los Angeles practice (Monday through Friday, 8:00 AM to 6:00 PM Pacific Time) will be billed at the emergency consultation rate specified in Item No. 6.
This Quotation Estimate is non-transferable and applies solely to the named client. Any change in patient identity requires a new evaluation and revised estimate.

By signing below, the client acknowledges receipt of this Quotation Estimate, agrees to the terms and conditions outlined herein, and authorizes the Psychiatrist at Westside Behavioral Health Associates to initiate the described psychiatric services in United States Los Angeles. The client further authorizes the release of relevant medical information to the insurance provider for the purpose of claim processing, in compliance with applicable privacy laws.

Client Signature: ___________________________

Printed Name: ___________________________

Date: ___________________________

Psychiatrist / Provider Signature: ___________________________

Dr. Margaret Chen, MD

License No.: CA-A-12345

Date: ___________________________

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