Billing Form

Therapist Billing Form

All fields marked with * are required and must be filled.
Name*

First NameLast Name
NPI Number *
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Notes:
Be sure to include ALL relevant details, such as new, shared, or transferred clients, re-evaluations, and any other updates. PLEASE add a note for approved late billing. *Associates, please include any co-pays that need to be billed as well.
Eligibility Re-checks (if applicable)
Please include client's name and when eligibility was cleared.
Sunday Billing

MonthDayYear
PLEASE make sure you select the correct Sunday that you are billing for.

Monday Billing

MonthDayYear
Please make sure you select the correct Monday that you are billing for.

Tuesday Billing

MonthDayYear
Please make sure you select the correct Tuesday that you are billing for.

Wednesday Billing

MonthDayYear
Please make sure you select the correct Wednesday that you are billing for.

Thursday Billing

MonthDayYear
Please make sure you select the correct Thursday that you are billing for.

Friday Billing

MonthDayYear
Please make sure you select the correct Friday that you are billing for.

Saturday Billing

MonthDayYear
Please make sure you select the correct Saturday that you are billing for.

Therapist Billing Form