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Mental Health Provider Services-Superbill by motorwilson

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Forms used in Psychotherapy Private Practice

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									Mental Health Provider Services
Mou Wilson, MA MFT
8235 Santa Monica Blve, Suite 400 West Hollywood, CA 90046 323-284-4423 LIC #MFC44134 EIN #20-8717899 NPI# 1578694410 DATE:_____________ Patient Name: ______________________________Date of Birth: _____________ Address:________________________________________________________ Phone:____________________ Social Security Number #: ________________ Insured Name: _________________________________________________________ Insurance Co.____________________________________________________ Group #: ________________________ Member #: ______________________ Dates of Visit/CPT Code: ______________90801 Dx Intake Assessment ______________90806 Individual Therapy ______________90853 Group Therapy ______________90847 Family Therapy # Visits @ Fee = Total ____@_________=_____ ____@_________=_____ ____@_________=_____ ____@_________=_____

Diagnosis Code:________________

Total Charges:_____ Total Paid: _______

I authorize the release of any medical information necessary to process this claim. Date Signature

Date

Signature of Provider


								
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