Hampton College Invoice Portal

Please select your Company or Organization

Provider Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Phone

Client Name

First

Last

Client Number

Visit Date / Time

Date

Time

Alabama State University clients receive ONE session for each application

Visit CPT Code

Comment

Please ONLY add invoice specific comments.

Billable Charge

I accept the universal flat rate per session.

Payment Choice

The person submitting this invoice is the owner or an authorized agent.

Signature

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