Partner Invoice Submission Form
Provide invoice details for an approved client, including payment and insurance information.
Your Full Name
*
First Name
Last Name
Name of Practice
*
Client ID
*
Session Date
*
-
Month
-
Day
Year
Date
Type of Service Provided
*
Therapy Session
Family Therapy
Couples Therapy
Intensive
Psychiatric Evaluation
Psychiatric Med Check
No Show Fee
Documentation (please describe)
Other
If documentation or other, describe here:
What is payment applied toward?
*
Copay
Deductible
Self-pay cost
Total Session Cost Due
*
Amount Paid by Client
*
Amount Owed by Foundation
*
Amount to be Paid by Insurance
*
Write NA if insurance was not used
Are you writing off any amount for the client?
*
Yes, the client will owe nothing further
No, they owe the remainder due
No, the foundation covered the entire expense
Anything else we should know?
Submit Invoice
Should be Empty: