|
Parent or Guardian Name
|
Patient Status
• • •
|
|
Date of service:
|
Appointment Time:
|
|
Start Date:
|
Insurance Company
• • •
|
|
Auth #
|
End Date;
|
|
|
|
|
Services
|
Service Description
|
|
Intake Part1 (min/hours)
|
Intake Part 2: (min/hours)
|
|
Therapy
• • •
|
QMHP
• • •
|
|
Therapy Group (min/hours)
|
CASII/LOCUS (min/hours)
|
|
Neurofeedback (min/hours)
|
Day Treatment (min/hours)
|
|
Basic Skills Training (min/hours)
|
Psychosocial Rehabilitation (min/hours)
|
|
EEG
|
I'm a second (min/hours)
|
|
EEG Analysis
|
Psychometric
|
|
|
Other (min/hours)
|
|
AXIS CPT CODES
|
|
|
|
|
|
Billing Office Only
|
|
|
Patient or Parent Guardian Signature
|
|
|
Provider Printed Name
|
Provider Signature
|
|
Default Diagnosis
|
|
|
Payment Received By
|
Amount to Collect Today
|
|
Payment Type
• • •
|
Amount Paid
|
|
|
|
|
2780 S.Jones Blvd.Suite 220 LV, NV 89146
|
Phone 702-323-1323
|
|
FORM 2015050
|
Fax 702-405-6036
|
