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MY WALK TO CARE

PROVIDER BILLING FORM

Provider First Name

Provider Email

Provider Last Name

Provider Phone

Practice or Group Name

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I understand I need to obtain an authorization number before seeing a client. I understand an authorization number is required to be reimbursed.

I understand My Walk of Life must receive this billing form by the sixth of each month.

I understand that billing forms received after the sixth may be processed during the next billing cycle.

I understand I do not suppose to hold onto billing until all sessions are completed. Sessions or claims submitted after two billing cycles will not be paid.

I understand no fees may be charged to the client including fees that may be lost due to faulty billing.

I understand fees may be charged to the client by your office for no shows based on your office policies and procedures.

How many sessions would you like to enter?

Authorization # (Session One)

Client First and Last Name (Session One)

Service Date (Session One)

Service Type (Session One)

Session Minutes (Session One)

Authorization # (Session Two)

Client First and Last Name (Session Two)

Service Date (Session Two)

Service Type (Session Two)

Session Minutes (Session Two)

Authorization # (Session Three)

Client First and Last Name (Session Three)

Service Date (Session Three)

Service Type (Session Three)

Session Minutes (Session Three)

Authorization # (Session Four)

Client First and Last Name (Session Four)

Service Date (Session Four)

Service Type (Session Four)

Session Minutes (Session Four)

Authorization # (Session Five)

Client First and Last Name (Session Five)

Service Date (Session Five)

Service Type (Session Five)

Session Minutes (Session Five)

Authorization # (Session Six)

Client First and Last Name (Session Six)

Service Date (Session Six)

Service Type (Session Six)

Session Minutes (Session Six)

Authorization # (Session Seven)

Client First and Last Name (Session Seven)

Service Date (Session Seven)

Service Type (Session Seven)

Session Minutes (Session Seven)

Authorization # (Session Eight)

Client First and Last Name (Session Eight)

Service Date (Session Eight)

Service Type (Session Eight)

Session Minutes (Session Eight)

Authorization # (Session Nine)

Client First and Last Name (Session Nine)

Service Date (Session Nine)

Service Type (Session Nine)

Session Minutes (Session Nine)

Authorization # (Session Ten)

Client First and Last Name (Session Ten)

Service Date (Session Ten)

Service Type (Session Ten)

Session Minutes (Session Ten)

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I understand I need to email admin@mywalkoflife.com if I would like a pdf copy for my records.

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HELPING THOSE IN NEED

The My Walk of Life Family are comprised of passionate Health Care Professionals and Community Advocates that share the same passion and vision towards enhancing Mental Health Education and Prevention as well as ensuring that anyone who is looking for Mental Health Care will not be deterred because of Affordability and Accessibility circumstances.

The need is urgent. Mental Health is important and you can make a difference today!

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OUR PARTNERS

My Walk of Life core mission is aligned with Community Collaboration and our Community Partnerships are essential to our organization fulfilling its desired goals. Our community partners include but are not limited to health care and mental health providers, social service agencies, non-profits, faith-based organizations, and other organizations or individuals who share the same visions and passion as we do. Meet our most valued Community Partners

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