Superbill Request Form

Superbill Request Form

Palo Alto Massage Therapy Center (MTC)
CAUTION: if you are requesting a superbill, DO NOT book your massage with Julie, Joy, Polly, or Bonne.
A. Client information
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Email*
example@example.com
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
B. Insurance information
YesNoNot sure
Insurance Carrier Name*
C. Services requested
Date range for massage sessions to be included (only massage sessions, not acupuncture sessions)*

MonthDayYear
Start date
MonthDayYear
End date
D. Reason for care
Neck painLower back painUpper back painShoulder painHeadachesMuscle pain / spasmInjury recoveryHip painKnee painArm painOther
If choose other, please enter below concisely
(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*

MonthDayYear
Should be Empty:

A. Client information