superbill:

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


Patient Name: ___________________________
Date of Birth: _________________________
Phone Number: __________________________
Insurance Company: _____________________
Policy Number: _________________________
Group Number: __________________________
Date of Service: _______________________
Referring Physician (if any): __________


Diagnosis (ICD-10 Codes)

Code Description
__________ __________________________
__________ __________________________
__________ __________________________


Procedures / Services (CPT/HCPCS Codes)

Code Description Fee ($) Modifiers Units
__________ ______________________ _______ _________ ______
__________ ______________________ _______ _________ ______
__________ ______________________ _______ _________ ______

Payment Method (circle one): Cash / Check / Credit Card / Insurance

Amount Paid: $_______________ (Amount Paid, This refers to what the patient has already paid you at the time of service.
This may include: Copay, Coinsurance, Full payment (if you are out-of-network or the patient is self-pay))


Balance Due: $_______________ (Balance Due
This is usually interpreted as the remaining amount you're billing the insurance company for, not what the patient
owes—unless the patient still has an unpaid portion)


Provider Signature: ___________________________
Date: _______________

"This is a statement of services for insurance reimbursement purposes only. Payment is not guaranteed."



Example Scenarios:
In-network (copay paid at visit)
Patient pays $30 copay.

Your full fee is $150.

Insurance is billed for the remaining $120.

Example Scenarios:
In-network (copay paid at visit)
Patient pays $30 copay.
Your full fee is $150.

Insurance is billed for the remaining $120.
Amount Paid: $30
Balance Due: $120
Out-of-network (patient pays in full, submits to insurance)
Patient pays full $150.

You give them a superbill to submit to insurance.
Amount Paid: $150
Balance Due: $0
No payment yet (billed to insurance)
Patient hasn’t paid anything yet.

You're billing insurance first.
Amount Paid: $0
Balance Due: $150