Mental Health Provider Services

CM Therapy, LLC
Caroline Miller, LPC
231 S. Bemiston Avenue, Suite 800
Clayton, MO 63105

EIN# 85-3623601

Date

Patient Name:

DOB

Address:

Phone:

SSN:

Insured Name:

Insurance Company:

Group #:

Member #:

Dates of Visit/CPT Code:

#Visits @ Fee = Total

_____ 90837 Individual Therapy

_____ 90847 Family Therapy

_____ 90853 Group Therapy

________@$________=$_____

Diagnosis Code:

Total Charges: $

Total Paid: $

I authorize the release of any medical information necessary to process this claim.

______________________________________________________________________________________

Date Signature

______________________________________________________________________________________

Date Signature of Provider

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