Multi-Visit Superbill Template

Provider Information

Provider Name: __________________________
Practice Name: __________________________
NPI Number: _____________________________
Tax ID (EIN or SSN): ____________________
Phone: _________________________________
Fax: ___________________________________
Address: _______________________________
City, State, ZIP: ______________________
Patient Information


Patient Name: ___________________________
Date of Birth: _________________________
Phone Number: __________________________
Insurance Company: _____________________
Policy Number: _________________________
Group Number: __________________________
Date Range for Services: _______________ to _______________
Diagnosis (ICD-10 Codes)

Code Description
__________ __________________________
__________ __________________________
__________ __________________________

Service Log (CPT/HCPCS Codes per Visit)

Date of Service CPT Code Description Fee ($) Modifiers Units Amount Paid Balance Due
____ ________ ____________________ _______ _________ ______ ____________ ____________
____ ________ ____________________ _______ _________ ______ ____________ ____________
____ ________ ____________________ _______ _________ ______ ____________ ____________
____ ________ ____________________ _______ _________ ______ ____________ ____________
____ ________ ____________________ _______ _________ ______ ____________ ____________

(Add more rows as needed)

Total Summary


Total Fee: $______________
Total Amount Paid by Patient: $______________
Total Balance Due: $______________
Provider Signature: ___________________________
Date: _______________

Optional: Add a disclaimer
“This superbill is provided to assist with out-of-network reimbursement. Payment is not guaranteed. Please contact your
insurance provider for coverage and reimbursement information.”