Diagnostic Billing HiddenYour Phone*Do not edit. Pre-filled for your convenience.HiddenEmail*Do not edit. Pre-filled for your convenience. Clinic Name* Practitioner Name* First Last Patient First Name* Patient Last Name* Diagnosis Given for This Patient*e.g. F84.0 Autism Date of Care* MM slash DD slash YYYY Services Provided by Licensed Psychologist 90791 Diagnostic Interview 90791 Diagnostic Interview - Done via Telehealth 96136 Psychological Testing (1st 30 minutes) 96137 Psychological Testing (additional 30 minutes) 96130 Psychological Testing Evaluation (1st 30 minutes) 96131 Psychological Testing Evaluation (additional 30 minutes) 96137 Units 96131 Units Services Provided by Licensed Clinical Social Worker 90791 Diagnostic Interview 96150 Health and Behavior Assessment - Initial (1st 15 minutes) 96151 Health and Behavior Assessment - Subsequent (Additional 15 min) 90887 Consultation with Family 90791 Diagnostic Interview - Done via Telehealth 90832 Individual Psychotherapy (30 minutes) 90832 Individual Psychotherapy (30 minutes) - Done via Telehealth 90834 Individual Psychotherapy (45 minutes) 90834 Individual Psychotherapy (45 minutes) - Done via Telehealth 90837 Individual Psychotherapy (60 minutes) 90837 Individual Psychotherapy (60 minutes) - Done via Telehealth 90846 Family Therapy without patient (50 minutes) 90846 Family Therapy without patient (50 minutes) - Done via Telehealth 90847 Family Therapy with patient (50 minutes) 90847 Family Therapy with patient (50 minutes) - Done via Telehealth 90849 Multi-family Group Therapy 90849 Multi-family Group Therapy - Done via Telehealth 90853 Group Therapy 96151 Units Do you have another date of service for this patient? Yes No 2nd Date of Care* MM slash DD slash YYYY Services Provided by Licensed Psychologist 90791 Diagnostic Interview 90791 Diagnostic Interview - Done via Telehealth 96136 Psychological Testing (1st 30 minutes) 96137 Psychological Testing (additional 30 minutes) 96130 Psychological Testing Evaluation (1st 30 minutes) 96131 Psychological Testing Evaluation (additional 30 minutes) 96137 Units 96131 Units Services Provided by Licensed Clinical Social Worker 90791 Diagnostic Interview 96150 Health and Behavior Assessment - Initial (1st 15 minutes) 96151 Health and Behavior Assessment - Subsequent (Additional 15 min) 90887 Consultation with Family 90791 Diagnostic Interview - Done via Telehealth 90832 Individual Psychotherapy (30 minutes) 90832 Individual Psychotherapy (30 minutes) - Done via Telehealth 90834 Individual Psychotherapy (45 minutes) 90834 Individual Psychotherapy (45 minutes) - Done via Telehealth 90837 Individual Psychotherapy (60 minutes) 90837 Individual Psychotherapy (60 minutes) - Done via Telehealth 90846 Family Therapy without patient (50 minutes) 90846 Family Therapy without patient (50 minutes) - Done via Telehealth 90847 Family Therapy with patient (50 minutes) 90847 Family Therapy with patient (50 minutes) - Done via Telehealth 90849 Multi-family Group Therapy 90849 Multi-family Group Therapy - Done via Telehealth 90853 Group Therapy 96151 Units Do you have another date of service for this patient? Yes No 3rd Date of Care* MM slash DD slash YYYY Services Provided by Licensed Psychologist 90791 Diagnostic Interview 90791 Diagnostic Interview - Done via Telehealth 96136 Psychological Testing (1st 30 minutes) 96137 Psychological Testing (additional 30 minutes) 96130 Psychological Testing Evaluation (1st 30 minutes) 96131 Psychological Testing Evaluation (additional 30 minutes) 96137 Units 96131 Units Services Provided by Licensed Clinical Social Worker 90791 Diagnostic Interview 96150 Health and Behavior Assessment - Initial (1st 15 minutes) 96151 Health and Behavior Assessment - Subsequent (Additional 15 min) 90887 Consultation with Family 90791 Diagnostic Interview - Done via Telehealth 90832 Individual Psychotherapy (30 minutes) 90832 Individual Psychotherapy (30 minutes) - Done via Telehealth 90834 Individual Psychotherapy (45 minutes) 90834 Individual Psychotherapy (45 minutes) - Done via Telehealth 90837 Individual Psychotherapy (60 minutes) 90837 Individual Psychotherapy (60 minutes) - Done via Telehealth 90846 Family Therapy without patient (50 minutes) 90846 Family Therapy without patient (50 minutes) - Done via Telehealth 90847 Family Therapy with patient (50 minutes) 90847 Family Therapy with patient (50 minutes) - Done via Telehealth 90849 Multi-family Group Therapy 90849 Multi-family Group Therapy - Done via Telehealth 90853 Group Therapy 96151 Units Check this box if applicable. Yes, please also do an ABA Therapy insurance verification for this patient, using an autism diagnosis. I understand that if the patient does not receive an autism diagnosis, the ABA Therapy benefits quoted may not apply. Δ
