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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/
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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
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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.
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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
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