Psychotherapy Superbill

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					                                                                                                      PRIVATE PRACTICE
                                                    Your Name, Degree
                                                    License Designation
      SED                                          Street Address, Suite #
 PROPO                                                 City, State, Zip
                                                 Area Code, Phone Number
                                                License (number, state, type)
                                              Tax ID or Social Security Number
  Services Billed To:

  Patient Account #:                                            Patient:

                      Patient Information                          Dates

      Policy Holder                                                Service                    Diagnosis

      Social Security Number                                       Total Sessions             Charge per session

      Street                                                            Total Charges

      City, State, Zip                                                  Adjustments

      Patient                                                           Payments

      Male         Female       Birthdate                               Prior Balance

      Insurance Carrier                                                 Late Charges

      Policy No.         Group No.                                      Balance Due
                                                                   Providers Signature
      Relationship to Policy Holder

                                                      Procedure Codes
   Evaluative Procedures                                      Special Services and Reports
     90801 Diagnostic interview examination                     99050 After office hours
     96101 Psychological testing                                99052 Between 10 p.m. and 8 a.m.
   Therapeutic Procedures                                       99054 On Sundays and holidays
     90804 Individual psychotherapy;                            99056 In a location other than office
           approximately 20-30 minutes                          99058 On an emergency basis
     90806 approximately 45-50 minutes                          99071 Educational supplies (books, tapes, etc.)
     90808 approximately 75-80 minutes                          99075 Medical testimony
     90846 Family (without the patient present)                 99078 Educational services in a group setting
     90847 Conjoint/family                                      99080 Special reports
     90849 Multiple-family group                                99082 Unusual travel
     90853 Group (other than multiple-family group)             99221 Initial hospital care
                                                                99231 Subsequent hospital care
   Other Psychiatric Therapy
     90880 Hypnotherapy                                       Team Conferences
     90882 Intervention with institutions                       99361 Approximately 30 minutes
     90887 Interpretation of procedures                         99362 Approximately 60 minutes
     90889 Report writing                                     Telephone Calls
     90899 Unlisted service or procedure                        99371 Telephone call
                                                                99372 Intermediate
                                                                99373 Complex or lengthy

Member Toll-Free Phone (888) 89-CAMFT                                           November/December 2003 · THE THERAPIST   23

Description: Psychotherapy Superbill document sample