Super Bill Request

Super Bill Request

Omni Health NP
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Invoice Number*
Date of Service*

MonthDayYear
Date
Type of visit*

TelehealthIn Person
By submitting this form, I authorize OmniHealth to release a superbill containing my protected health information, including CPT and ICD-10 diagnosis codes, to me via the delivery method selected above. I acknowledge that reimbursement is not guaranteed and varies by plan.

By submitting this request, I agree to the Privacy Policy and Terms of Service of Omni Health NP.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: