C1216 PSYCHOLOGY SERVICES Family Counselling Services Invoice P.O. BOX 2415 EDMONTON, AB T5J 2S5 FAX: (780) 498-3211 1-800-661-1993 please senD to psychology consultant services for Review - fax to: 780-498-3211 or mail to: millard psychology consulting, 131 airport road, edmonton AB T5G 0W6 WCB Claim # Worker’s Surname First Name and Initial Date of Birth (yyyy/mm/dd) Family Member’s Surname Family Member’s First Name Date of Accident (yyyy/mm/dd) SERVICE COMPONENTS Service Date of Service Description Units Fee Code (yyyy/mm/dd) PFC01 $170 per hour Family Psychological Counselling PFC01 $170 per hour Family Psychological Counselling PFC01 $170 per hour Family Psychological Counselling PFC01 $170 per hour Family Psychological Counselling PFCR01E $70.00 Initial Report Fee (Timely) Initial Report Fee (Late) PFCR01L $32.50 PFCR02 $25.00 Progress Report Fee PFCR03E $45.00 Discharge Report Fee(Timely) PFCR03L $35.00 Discharge Report Fee (Late) MISCELLANEOUS (See Legend on back) Service # of Date End Date Description Amount Code Units (yyyy/mm/dd) (yyyy/mm/dd) $ $ $ Amount Billed $ Signature Name and Address to Whom Fee is Payable (please print) Print Name Psychologist’s Name: Telephone Number Fax Number Psychologist’s Billing Number: Reference Number Date (yyyy/mm/dd)
P.O. BOX 2415 EDMONTON, AB T5J 2S5 FAX: (780) 498-3211 1-800-661-1993 C1216 PSYCHOLOGY SERVICES Family Counselling Services Invoice please senD to psychology consultant services for Review - fax to: 780-498-3211 or mail to: millard psychology consulting, 131 airport road, edmonton AB T5G 0W6 WCB Claim # Worker’s Surname First Name and Initial Date of Birth (yyyy/mm/dd) Family Member’s Surname Family Member’s First Name Date of Accident (yyyy/mm/dd) SERVICE COMPONENTS Date of Service (yyyy/mm/dd) Description Service Code Units Fee Family Psychological Counselling PFC01 $170 per hour Family Psychological Counselling PFC01 $170 per hour Family Psychological Counselling PFC01 $170 per hour Family Psychological Counselling PFC01 $170 per hour Initial Report Fee (Timely) PFCR01E $70.00 Initial Report Fee (Late) PFCR01L $32.50 Progress Report Fee PFCR02 $25.00 Discharge Report Fee(Timely) PFCR03E $45.00 Discharge Report Fee (Late) PFCR03L $35.00 MISCELLANEOUS (See Legend on back) Date (yyyy/mm/dd) End Date (yyyy/mm/dd) Service Code # of Units Description Amount $ $ $ Amount Billed $ Name and Address to Whom Fee is Payable (please print) Psychologist’s Name: Psychologist’s Billing Number: Signature Print Name Telephone Number Fax Number Reference Number Date (yyyy/mm/dd)
C1216.docx