• Therapist Billing Form

    All fields marked with * are required and must be filled.
  • FULL Name*
  • Format: (000) 000-0000.
  • Billing Under*
  • Sunday Billing
     - -
    2 digit month, 2 digit day, 4 digit year
  • *
  • OLD Sunday Sessions
    Rows
  • Monday Billing
     - -
    2 digit month, 2 digit day, 4 digit year
  • *
  • OLD Monday Sessions
    Rows
  • Tuesday Billing
     - -
    2 digit month, 2 digit day, 4 digit year
  • *
  • OLD Tuesday Sessions
    Rows
  • Wednesday Billing
     - -
    2 digit month, 2 digit day, 4 digit year
  • *
  • OLD Wednesday Sessions
    Rows
  • Thursday Billing
     - -
    2 digit month, 2 digit day, 4 digit year
  • *
  • OLD Thursday Sessions
    Rows
  • Friday Billing
     - -
    2 digit month, 2 digit day, 4 digit year
  • *
  • OLD Friday Sessions
    Rows
  • Saturday Billing
     - -
    2 digit month, 2 digit day, 4 digit year
  • *
  • OLD Saturday Sessions
    Rows

  • When reviewing and before clicking submit, PLEASE double-check the following:

    Ensure that the correct dates are selected for each billing day.

    Session Start and End times include AM/PM

    Sessions listed are in order of occurrance (i.e. 9am, 10am, then 12pm)

    Verify that ALL relevant notes and eligibility recheck dates are included.

    Confirm that all times and CPT codes are accurate and match what is in TherapyNotes.

  • Should be Empty: