CHILDREN’S ADMINISTRATION DATE OF INVOICE PSYCHOLOGICAL SERVICES BILLING STATEMENT DIVISION OF CHILDREN AND FAMILY SERVICES Provider Name FamLink Provider ID Phone Provider’s Address Provider’s CA Social Worker Phone Number CA Office FamLink Case ID Name Phone Number Client’s Client’s Service Provided Service Time % Amount Billed Total Due Psychological Evaluation # of hours $ per hour $ (Testing with interpretation and report) Neuropsychological testing battery and status exam with interpretation and report # of hours $ per hour $ (Conducted in addition to a Psychological Evaluation) Parental Evaluation/Parenting Component (Conducted in addition to a Psychological or # of hours $ per hour $ evaluation) Professional Consultations with CA staff or other # of hours $ per hour $ authorized parties With report 1 Unit = 30 minute Individual psychotherapy with report # of units $ per unit $ Family group of 2 or more -- Psychotherapy & report # of units $ per unit $ WITH client present Family group of 2 or more -- Psychotherapy & report # of units $ per unit $ WITHOUT client present $ per hr, per Group Psychotherapy with unrelated individuals # of hours $ person Allowed hours & rates are posted at % cannot exceed what CA authorized. Date Description of Tasks (client interview, written testing, report writing, etc.) Hours Include a copy of the signed referral and the final report with this invoice. COMMENTS: ________________________________________________________________________________________ Provider Signature
CHILDREN’S ADMINISTRATION PSYCHOLOGICAL SERVICES BILLING STATEMENT DIVISION OF CHILDREN AND FAMILY SERVICES DATE OF INVOICE Provider Name FamLink Provider ID Provider’s Address Provider’s Phone CA Social Worker Phone Number CA Office FamLink Case ID Client’s Name Client’s Phone Number Service Provided Service Time % Amount Billed Total Due Psychological Evaluation (Testing with interpretation and report) # of hours $ per hour $ Neuropsychological testing battery and status exam with interpretation and report (Conducted in addition to a Psychological Evaluation) # of hours $ per hour $ Parental Evaluation/Parenting Component (Conducted in addition to a Psychological or evaluation) # of hours $ per hour $ Professional Consultations with CA staff or other authorized parties With report # of hours $ per hour $ 1 Unit = 30 minute Individual psychotherapy with report # of units $ per unit $ Family group of 2 or more -- Psychotherapy & report WITH client present # of units $ per unit $ Family group of 2 or more -- Psychotherapy & report WITHOUT client present # of units $ per unit $ Group Psychotherapy with unrelated individuals # of hours $ per hr, per person $ Allowed hours & rates are posted at % cannot exceed what CA authorized. Date Description of Tasks (client interview, written testing, report writing, etc.) Hours Include a copy of the signed referral and the final report with this invoice. COMMENTS: ________________________________________________________________________________________ Provider Signature
PSYCHOLOGICALSERVICES-BILLINGSTATEMENT.docx