Skip to main content
Find A Therapist
About BLHF
Programs
Events
Resources
Get Involved
News
Blog
More
Give Joy
Menu
Find A Therapist
About BLHF
Programs
Hangouts
Scholarship Fund
Events
Resources
Community Resources
Provider Resources
Educator Resources
Get Involved
Our Partners
Press
Blog
Prince George’s County School Invoice Portal
Prince George's County Public School Mental Alliance Invoice Portal
This is the only authorized source to submit an invoice for the Partnered Schools. Please use the link below for all other Mental Wellness Programs: https://borislhensonfoundation.org/mwsp-provider-invoice-portal/
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 3
Please select your Company or Organization
*
Please select your business
CapitolHill Consortium for Counseling & Consultation, LLC (CCCC)
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
Phone
*
Next
Service Provider
Provider Name
*
First
Last
Client
Client Name
*
First
Last
Client Number
*
Client Session Number
*
1st session
2nd session
3rd session
4th session
5th session
Visit Date / Time
*
Date
Time
Visit CPT Code
*
90836: Forty-five minutes of individual psychotherapy performed with an E/M service
90837: Sixty minutes of individual psychotherapy
90838: Sixty minutes of individual psychotherapy performed with an E/M service
90847: Family psychotherapy with the patient present
90846: Family psychotherapy without the patient present
Other
Other CPT Code
Is this invoice for the final session?
*
Yes
No
Comment
Please ONLY add invoice specific comments.
Previous
Next
Billable Charge
*
Universal Flat Rate - $150.00
I accept the universal flat rate per session.
Authorized Agent's Name and Title
*
Payment Choice
*
Direct Deposit (ACH Transfer) - 14 business day processing
The person submitting this invoice is the owner or an authorized agent.
*
Owner / Provider
Authorized Agent
Signature
*
Clear Signature
Previous
Website
Submit
Subscribe to the Newsletter
Email
CAPTCHA
Δ
