Superbill Request Form

Superbill Request Form

Palo Alto Massage Therapy Center (MTC)
CAUTION:

(1) if you are requesting a superbill, DO NOT book your massage with Julie, Joy, Polly, or Bonne.

(2) submit superbill request no more than once a month, and only after your services are complete.
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
Are you submitting this to your insurance for out-of-network reimbursement?
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
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

MonthDayYear
Should be Empty:

Superbill Request Form

A. Client information

B. Insurance information

C. Services requested

D. Reason for care