Superbill Reimbursement

Superbill Reimbursement Request

To help you submit out-of-network claims to your insurance provider, please complete the form below. These are the essential details that nearly all insurance plans require when processing superbills. Providing accurate information ensures your claim can be reviewed and processed smoothly.

Patient & Subscriber Information

First Name

Last Name

Client's Date of Birth

YYYY

Subscriber/Policyholder Name (if different from client)

Subscriber Date of Birth

YYYY

Relationship to Subscriber (self, spouse, child, other)

Insurance Company Name

Insurance Plan Type

Insurance ID / Policy Number

Group Number (if applicable)

Claim Number (if applicable)

Insurance Phone Number

Found on insurance card

(###)

###

####

Patient's Mailing Address

This will be needed for submitting superbills.

Client Email

Client Phone Number

Country

(###)

###

####

Preferred Communication Method

Service Dates for Reimbursement

Provider(s) Seen

Individual Therapy, Nutrition Counseling, Residential Care, etc.

Authorization & Acknowledgment

I confirm that the above information is accurate to the best of my knowledge and that I am requesting a superbill for submission to my insurance provider for potential out-of-network reimbursement.

Acknowledgment of Electronic Communication Risks

By submitting this form through this web portal, you acknowledge and accept the risks associated with sharing your health information via unencrypted electronic messaging. You choose to proceed despite these risks. By clicking "Yes, I want to submit this form," you agree to hold Charis Eating Disorder Care harmless for any unauthorized use, disclosure, or access of your protected health information transmitted through this electronic method.

Yes, I want to submit this form & agree to the terms of use