DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA) Psychologist and Sex Offender Treatment Provider Invoice CLIENT NAME DATE(S) PROVIDED YEAR DDA CASE RESOURCE MANAGER Note: Services must be pre-approved by DDA. SERVICE CODE SERVICE PROVIDED DATE(S) PROVIDED FEE CODE MODIFIER Psychological Evaluation / Non-Sexual Risk 99499 U3 Assessment Psychological Evaluation / Sexual Deviancy 99499 U1 Risk Assessment Brief Evaluation / Follow-up, Additional 99499 U4 Testing (per hour) Individual Therapy H2019 Group Therapy H2019 HQ Treatment Team Meeting (attendance and 99366 participation); Special Consultation or Limited Consultation (DDA staff, family, U6 S5115 contracted service providers; telephone calls, written reports (see Statement of Work paid – once per quarter) Polygraph Examination SA030 Penile Plethysmograph Testing (with written 54240 report) Total NAME OF PERSON PERFORMING THE SERVICE PROVIDER NUMBER COMPANY / AGENCY SIGNATURE DATE SENT TO DDA CASE MANAGER
DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA) Psychologist and Sex Offender Treatment Provider Invoice CLIENT NAME DATE(S) PROVIDED YEAR DDA CASE RESOURCE MANAGER Note: Services must be pre-approved by DDA. SERVICE PROVIDED SERVICE CODE CODE MODIFIER DATE(S) PROVIDED FEE Psychological Evaluation / Non-Sexual Risk Assessment 99499 U3 Psychological Evaluation / Sexual Deviancy Risk Assessment 99499 U1 Brief Evaluation / Follow-up, Additional Testing (per hour) 99499 U4 Individual Therapy H2019 Group Therapy H2019 HQ Treatment Team Meeting (attendance and participation); or Special Consultation 99366 Limited Consultation (DDA staff, family, contracted service providers; telephone calls, written reports (see Statement of Work – paid once per quarter) S5115 U6 Polygraph Examination SA030 Penile Plethysmograph Testing (with written report) 54240 Total NAME OF PERSON PERFORMING THE SERVICE PROVIDER NUMBER COMPANY / AGENCY SIGNATURE DATE SENT TO DDA CASE MANAGER
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