Super Bill/Out of Network Summary Request
To request a "super bill" or out of network summary to mail in to your insurance company, please fill out the form below. Due to the volume of requests I receive, please direct all inquiries for these summaries to the form below instead of email or text message. This will help to ensure that I complete them in a timely manner. Thank you!
Name
First Name
Last Name
I would like to request a super bill/out of network summary for therapy sessions between (select first session date you would like to appear on form):
-
Month
-
Day
Year
Date
and (select last session date you would like to appear on form):
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Month
-
Day
Year
Date
Email address (the super bill/reimbursement form will be emailed to this address):
example@example.com
By signing below, I acknowledge that reimbursements and deductibles are dependent upon my insurance plan, and Samantha Griffitts, MA, LMFT is unable to guarantee that I will be reimbursed or that session fees will be counted towards my deductible. I acknowledge that there will likely be a delay of 1-2 weeks between submitting this request form and receiving the document via email. I acknowledge that the form I will receive via email will include diagnostic and session codes, and that I will need to complete the form myself with other necessary information required by my insurance company before mailing in the form.
Submit
Should be Empty: