Rise N Shine Hypnosis and Counseling Super Bill for Client Reimbursement
       ​4215 N Brown Ave Suite D   *   Scottsdale, AZ 85251     *    217-433-5759      *   gloriike@gmail.com
                                         LPC-16270   Tax ID:  20 229 2013    NPI:  159 88 34160 

Client Serviced: ______________________________  Diagnostic code:  ________Procedural code:  _______    CPT Code: ___________       Date of Service: _____________       Fee:  __________                                                                 ​CPT Code: ___________     Date of Service: _______________       Fee: __________
 CPT Code: ___________     Date of Service:  ______________         Fee: _________ 
CPT Code:  __________      Date of Service: ______________          Fee: __________
                                                                                      Total payment:  ____________
90791  Initial Assessment- dx eval    90837  Ind session: 60 min  90785  Interactive Complexity – add on  90847  Family/couples            Gloria Eichenauer, Licensed Professional Counselor __________________________________________________________