Superbill Request Form

Superbill Request Form

This form is designed for clients who wish to receive an itemized superbill to submit to their insurance company. Please note: submission of a superbill does not guarantee that your insurance company will provide any reimbursement, but is a courtesy service provided by our office.
Client's Full Name *

First NameLast Name
Client's Date of Birth*

MonthDayYear
Date
Client's Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
Where you wish us to send the superbill PDF.
Therapist Name*
I am requesting a superbill for all appointments occurring between the dates of Start Date and End Date .
Is there anything you would like our team to know about this request?
I understand that my superbill will be completed as quickly as possible, which typically means 5 business days from the date the request was received. I also consent for the therapist selected above to be contacted regarding this request.*

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