Superbill Request Form

CAUTION: if you are requesting a superbill, DO NOT book your massage with Julie, Joy, Polly, or Bonne.

Name

First NameLast Name

Date of birth

Date

Email

example@example.com

Client Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you submitting this to your insurance for out-of-network reimbursement?

Insurance Carrier Name

Date range for massage sessions to be included (only massage sessions, not acupuncture sessions)

Start date

End date

Primary reason for massage (pick one)

If choose other, please enter below concisely

Superbill Acknowledgement

(1) I understand that MTC does not bill insurance and that a superbill is a receipt I may submit to my insurance for possible out-of-network reimbursement. (2) I understand that insurance reimbursement is not guaranteed and is determined solely by my insurance plan. (3) I understand that I am responsible for submitting the superbill to my insurance company and for all follow-up regarding my claim. (4) I understand that MTC does not verify insurance benefits, contact insurance companies, or revise diagnoses to influence coverage. (5) I confirm that the information I provided is accurate and complete.

Signature

Today's date

Superbill Request Form

A. Client information

B. Insurance information

C. Services requested

D. Reason for care