Request For Private Pay Invoice

Location *

Patient First Name *

Patient Last Name *

Patient Type or Classification *

Patient Type ID Number

Family Member Responsible for Billing — First Name

Family Member Responsible for Billing — Last Name

Patient or Point of Contact Email Address *

Family Member Phone *

Payment Option

Service Performed / Description *

Total Service Hours *

Hourly Rate / Bill Rate (e.g. 12.00) *

Total Amount Due

Service Start Date *

Service End Date *

Invoice Date *

Payment Due Date *

Frequency of Invoice *

Date of The First Payment

What Were the Duties Performed for the Patient? *

Activity Codes Performed (comma-separated, e.g. 20, 21, 27)

Private Insurance Name *

Additional Identification Number Requirement *

Additional Identification / Unique Identifier Number (0 = N/A) *