Compassion Centered Therapyfor Women SuperbillSuperbillAZ LCSW17608 and CA LCSW17890info@CompassionCenteredTherapyforWomen.com480-501-0600 Name First Last Date MM slash DD slash YYYY FeePrevious BalanceBalance DuePaymentRemaining BalancePlace of Service Office Hospital OtherDate of Service MM slash DD slash YYYY Code9079190832908349083796100908469084790848908539088590882908879088998910989129892098922ServiceDiagnostic EvaluationIndividual Psychotherapy (30 mins)Individual Psychotherapy (45 mins)Individual Psychotherapy (60 mins)Psych Testing (per hr)Family Psychotherapy (without client present)Family Psychotherapy (with client present)Couples TherapyGroup PsychotherapyEvaluation of RecordsCase ManagementExplanation of Evaluation to FamilyPreparation of ReportConference with Team (30 mins)Conference with Team (60 mins)Telephone Consultation (Brief)Telephone ConsultationFeeDiagnosis CodeTherapist's SignatureAuthorization to Pay Benefits to Licensed Clinical Social WorkerI hereby authorize payment directly to the undersigned Licensed Clinical Social Worker of the Medical Benefits, if any, otherwise payable to me for his/her services as described below but not to exceed the reasonable and customary charge for these services.Signature (Insured Person)(Required)Date(Required) MM slash DD slash YYYY Authorization to Release InformationI hereby authorize the undersigned Licensed Clinical Social Worker to release any information acquired in the course of my examination or treatment.Signature (Client or Parent, if Minor)(Required)Date(Required) MM slash DD slash YYYY
