Out-of-network healthcare providers who do not bill insurance directly — including therapists, psychologists, psychiatrists, chiropractors, acupuncturists, physical therapists, and some physicians in cash-based or concierge practices — typically issue superbills to patients.

Will my insurance reimburse 100% of the superbill amount?

Reimbursement depends on your plan's out-of-network benefits, deductible, and coinsurance. Many plans reimburse 50%–80% of the 'usual, customary, and reasonable' (UCR) rate, which may be lower than the provider's actual fee.

What CPT codes do therapists commonly use?

Common therapy CPT codes include 90837 (Individual psychotherapy, 60 min), 90834 (Individual psychotherapy, 45 min), 90832 (Individual psychotherapy, 30 min), 90847 (Family therapy with patient present), and 90853 (Group therapy). Always use the code that matches the actual service provided.

Free Superbill Template — Fill Out & Download Instantly

Free — No Sign-Up RequiredPDF & WordUpdated April 16, 2026

A superbill is a detailed medical invoice that contains all the information an insurance company needs to process a reimbursement claim when a patient pays out-of-pocket for medical services. Unlike a standard receipt, a superbill includes the provider's National Provider Identifier (NPI), Tax ID, diagnosis codes (ICD-10), procedure codes (CPT), place of service, referring physician information, and the patient's insurance details.

⚠️ Legal Disclaimer: This template is attorney-reviewed and built to US legal standards. It does not substitute for professional legal advice. For complex situations, we recommend consulting a licensed attorney.

Document Completeness0%

Practice / Clinic Name*

NPI (National Provider Identifier)*

Tax ID / EIN*

Practice Address*

Practice Phone*

Treating Provider Name*

Provider Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Insurance Company*

Member / Subscriber ID*

Group Number

Date of Service*

MM/DD/YYYY

Place of Service Code*

ICD-10 Diagnosis Code 1 (Primary)*

ICD-10 Diagnosis Code 2 (Secondary)

CPT Code 1*

Description of Service 1*

Units 1*

Fee 1 ($)*

CPT Code 2 (Optional)

Description of Service 2 (Optional)

Units 2

Fee 2 ($)

Total Charges ($)*

Amount Paid at Time of Service ($)*

Balance Due ($)*

Referring Physician (if applicable)

Practice / Clinic Name*

NPI (National Provider Identifier)*

Tax ID / EIN*

Practice Address*

Practice Phone*

Treating Provider Name*

Provider Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Insurance Company*

Member / Subscriber ID*

Group Number

Date of Service*

MM/DD/YYYY

Place of Service Code*

ICD-10 Diagnosis Code 1 (Primary)*

ICD-10 Diagnosis Code 2 (Secondary)

CPT Code 1*

Description of Service 1*

Units 1*

Fee 1 ($)*

CPT Code 2 (Optional)

Description of Service 2 (Optional)

Units 2

Fee 2 ($)

Total Charges ($)*

Amount Paid at Time of Service ($)*

Balance Due ($)*

Referring Physician (if applicable)

Practice / Clinic Name*

NPI (National Provider Identifier)*

Tax ID / EIN*

Practice Address*

Practice Phone*

Treating Provider Name*

Provider Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Insurance Company*

Member / Subscriber ID*

Group Number

Date of Service*

MM/DD/YYYY

Place of Service Code*

ICD-10 Diagnosis Code 1 (Primary)*

ICD-10 Diagnosis Code 2 (Secondary)

CPT Code 1*

Description of Service 1*

Units 1*

Fee 1 ($)*

CPT Code 2 (Optional)

Description of Service 2 (Optional)

Units 2

Fee 2 ($)

Total Charges ($)*

Amount Paid at Time of Service ($)*

Balance Due ($)*

Referring Physician (if applicable)

Practice / Clinic Name*

NPI (National Provider Identifier)*

Tax ID / EIN*

Practice Address*

Practice Phone*

Treating Provider Name*

Provider Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Insurance Company*

Member / Subscriber ID*

Group Number

Date of Service*

MM/DD/YYYY

Place of Service Code*

ICD-10 Diagnosis Code 1 (Primary)*

ICD-10 Diagnosis Code 2 (Secondary)

CPT Code 1*

Description of Service 1*

Units 1*

Fee 1 ($)*

CPT Code 2 (Optional)

Description of Service 2 (Optional)

Units 2

Fee 2 ($)

Total Charges ($)*

Amount Paid at Time of Service ($)*

Balance Due ($)*

Referring Physician (if applicable)

Practice / Clinic Name*

NPI (National Provider Identifier)*

Tax ID / EIN*

Practice Address*

Practice Phone*

Treating Provider Name*

Provider Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Insurance Company*

Member / Subscriber ID*

Group Number

Date of Service*

MM/DD/YYYY

Place of Service Code*

ICD-10 Diagnosis Code 1 (Primary)*

ICD-10 Diagnosis Code 2 (Secondary)

CPT Code 1*

Description of Service 1*

Units 1*

Fee 1 ($)*

CPT Code 2 (Optional)

Description of Service 2 (Optional)

Units 2

Fee 2 ($)

Total Charges ($)*

Amount Paid at Time of Service ($)*

Balance Due ($)*

Referring Physician (if applicable)

Practice / Clinic Name*

NPI (National Provider Identifier)*

Tax ID / EIN*

Practice Address*

Practice Phone*

Treating Provider Name*

Provider Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Insurance Company*

Member / Subscriber ID*

Group Number

Date of Service*

MM/DD/YYYY

Place of Service Code*

ICD-10 Diagnosis Code 1 (Primary)*

ICD-10 Diagnosis Code 2 (Secondary)

CPT Code 1*

Description of Service 1*

Units 1*

Fee 1 ($)*

CPT Code 2 (Optional)

Description of Service 2 (Optional)

Units 2

Fee 2 ($)

Total Charges ($)*

Amount Paid at Time of Service ($)*

Balance Due ($)*

Referring Physician (if applicable)

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SUPERBILL / STATEMENT FOR INSURANCE REIMBURSEMENT

PROVIDER INFORMATION

Practice Name: [Practice / Clinic Name]

Address: [Practice Address]

Phone: [Practice Phone]

NPI: [NPI (National Provider Identifier)]

Tax ID / EIN: [Tax ID / EIN]

Treating Provider: [Treating Provider Name], [Provider Credentials]

PATIENT INFORMATION

Patient Name: [Patient Full Name]

Date of Birth: [Patient Date of Birth]

Insurance: [Insurance Company]

Member ID: [Member / Subscriber ID]

Group Number: [Group Number]

SERVICE INFORMATION

Date of Service: [Date of Service]

Place of Service: [Place of Service Code]

DIAGNOSIS CODES (ICD-10)

Dx 1: [ICD-10 Diagnosis Code 1 (Primary)]

SERVICES RENDERED

CPT Code Description Units Fee

[CPT Code 1] [Description of Service 1] [Units 1] $[Fee 1 ($)]

FINANCIAL SUMMARY

Total Charges: $[Total Charges ($)]

Amount Paid at Time of Service: $[Amount Paid at Time of Service ($)]

Balance Due: $[Balance Due ($)]

PROVIDER SIGNATURE

I certify that the services described above were medically necessary and were personally rendered by me or under my direct supervision.

_______________________________ Date: _______________

[Treating Provider Name], [Provider Credentials]

NPI: [NPI (National Provider Identifier)]

INSTRUCTIONS FOR PATIENT

To seek reimbursement from your insurance company:

1. Complete your insurance company's out-of-network claim form.

2. Attach this superbill as supporting documentation.

3. Submit to the address or portal shown on your insurance card.

4. Keep a copy for your records.

5. Reimbursement timelines vary by plan. Contact your insurer for status updates.

This document may also be used for HSA/FSA reimbursement claims.

Document Completeness0%

Practice / Clinic Name*

NPI (National Provider Identifier)*

Tax ID / EIN*

Practice Address*

Practice Phone*

Treating Provider Name*

Provider Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Insurance Company*

Member / Subscriber ID*

Group Number

Date of Service*

MM/DD/YYYY

Place of Service Code*

ICD-10 Diagnosis Code 1 (Primary)*

ICD-10 Diagnosis Code 2 (Secondary)

CPT Code 1*

Description of Service 1*

Units 1*

Fee 1 ($)*

CPT Code 2 (Optional)

Description of Service 2 (Optional)

Units 2

Fee 2 ($)

Total Charges ($)*

Amount Paid at Time of Service ($)*

Balance Due ($)*

Referring Physician (if applicable)

Practice / Clinic Name*

NPI (National Provider Identifier)*

Tax ID / EIN*

Practice Address*

Practice Phone*

Treating Provider Name*

Provider Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Insurance Company*

Member / Subscriber ID*

Group Number

Date of Service*

MM/DD/YYYY

Place of Service Code*

ICD-10 Diagnosis Code 1 (Primary)*

ICD-10 Diagnosis Code 2 (Secondary)

CPT Code 1*

Description of Service 1*

Units 1*

Fee 1 ($)*

CPT Code 2 (Optional)

Description of Service 2 (Optional)

Units 2

Fee 2 ($)

Total Charges ($)*

Amount Paid at Time of Service ($)*

Balance Due ($)*

Referring Physician (if applicable)

Practice / Clinic Name*

NPI (National Provider Identifier)*

Tax ID / EIN*

Practice Address*

Practice Phone*

Treating Provider Name*

Provider Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Insurance Company*

Member / Subscriber ID*

Group Number

Date of Service*

MM/DD/YYYY

Place of Service Code*

ICD-10 Diagnosis Code 1 (Primary)*

ICD-10 Diagnosis Code 2 (Secondary)

CPT Code 1*

Description of Service 1*

Units 1*

Fee 1 ($)*

CPT Code 2 (Optional)

Description of Service 2 (Optional)

Units 2

Fee 2 ($)

Total Charges ($)*

Amount Paid at Time of Service ($)*

Balance Due ($)*

Referring Physician (if applicable)

Practice / Clinic Name*

NPI (National Provider Identifier)*

Tax ID / EIN*

Practice Address*

Practice Phone*

Treating Provider Name*

Provider Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Insurance Company*

Member / Subscriber ID*

Group Number

Date of Service*

MM/DD/YYYY

Place of Service Code*

ICD-10 Diagnosis Code 1 (Primary)*

ICD-10 Diagnosis Code 2 (Secondary)

CPT Code 1*

Description of Service 1*

Units 1*

Fee 1 ($)*

CPT Code 2 (Optional)

Description of Service 2 (Optional)

Units 2

Fee 2 ($)

Total Charges ($)*

Amount Paid at Time of Service ($)*

Balance Due ($)*

Referring Physician (if applicable)

Practice / Clinic Name*

NPI (National Provider Identifier)*

Tax ID / EIN*

Practice Address*

Practice Phone*

Treating Provider Name*

Provider Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Insurance Company*

Member / Subscriber ID*

Group Number

Date of Service*

MM/DD/YYYY

Place of Service Code*

ICD-10 Diagnosis Code 1 (Primary)*

ICD-10 Diagnosis Code 2 (Secondary)

CPT Code 1*

Description of Service 1*

Units 1*

Fee 1 ($)*

CPT Code 2 (Optional)

Description of Service 2 (Optional)

Units 2

Fee 2 ($)

Total Charges ($)*

Amount Paid at Time of Service ($)*

Balance Due ($)*

Referring Physician (if applicable)

Practice / Clinic Name*

NPI (National Provider Identifier)*

Tax ID / EIN*

Practice Address*

Practice Phone*

Treating Provider Name*

Provider Credentials*

Patient Full Name*

Patient Date of Birth*

MM/DD/YYYY

Insurance Company*

Member / Subscriber ID*

Group Number

Date of Service*

MM/DD/YYYY

Place of Service Code*

ICD-10 Diagnosis Code 1 (Primary)*

ICD-10 Diagnosis Code 2 (Secondary)

CPT Code 1*

Description of Service 1*

Units 1*

Fee 1 ($)*

CPT Code 2 (Optional)

Description of Service 2 (Optional)

Units 2

Fee 2 ($)

Total Charges ($)*

Amount Paid at Time of Service ($)*

Balance Due ($)*

Referring Physician (if applicable)

What Is a Superbill Template?

When Do You Need It?

A superbill is needed when a healthcare provider does not participate directly in a patient's insurance network, or when a patient pays out-of-pocket at the time of service and wants to seek reimbursement from their insurance company. Therapists in private practice, cash-based medical practices, and concierge medicine providers routinely issue superbills. Patients need a superbill to submit an out-of-network insurance claim, to meet their deductible, or to be reimbursed from a Health Savings Account (HSA) or Flexible Spending Account (FSA)..

What's Included in This Template

Practice name, address, and phone number
National Provider Identifier (NPI)
Tax ID / EIN
Physician name and credentials
Patient name, date of birth, and insurance information
Member ID and group number
Date and place of service
ICD-10 diagnosis codes (up to 2)
CPT procedure codes with descriptions, units, and fees
Total charges, insurance payments, adjustments, and balance due
Referring physician information

How to Fill It Out

Enter Practice and Provider Information — Fill in your practice name, physical address, and phone number. Enter your NPI (National Provider Identifier) — required for all insurance claims — and your Tax ID or EIN. Add the treating physician or therapist's name and credentials (e.g., MD, PhD, LCSW, DC).

Enter Patient and Insurance Information — Provide the patient's full legal name, date of birth, and complete insurance information including the insurance company name, member/subscriber ID, and group number. This information typically appears on the patient's insurance card.

Enter Service Details — Enter the date of service and the place of service code (e.g., 11 for office, 02 for telehealth). This information is required by insurance companies to process the claim correctly.

Enter Diagnosis Codes (ICD-10) — Enter the ICD-10 diagnosis code(s) that apply to the patient's condition. ICD-10 codes are standardized codes that identify the medical diagnosis. Examples: F41.1 (Generalized Anxiety Disorder), M54.5 (Low back pain). Use the primary diagnosis as Code 1.

Enter Procedure Codes (CPT) — Enter the CPT (Current Procedural Terminology) codes for services rendered, along with a description, number of units, and fee for each. Common examples: 90837 (Individual psychotherapy, 60 min), 99213 (Office visit, established patient, moderate complexity).

Calculate Totals and Sign — Total all service fees, subtract any insurance payments already made and any adjustments, and enter the remaining patient balance. Add the referring physician's information if applicable, then sign and date the superbill.

Legal Requirements & Notes

A superbill is not a guarantee of insurance reimbursement. Coverage depends on the patient's specific plan, deductible status, and out-of-network benefits. Providers should ensure that CPT and ICD-10 codes are accurate and appropriate for the services rendered. Fraudulent billing codes constitute healthcare fraud under federal law. Always use current-year CPT and ICD-10 codes as they are updated annually. This template is for educational purposes and does not constitute legal, medical, or billing advice.

Frequently Asked Questions

A regular invoice shows what you owe and payment instructions. A superbill contains all the structured medical billing information (NPI, Tax ID, CPT codes, ICD-10 codes, place of service) that an insurance company needs to process an out-of-network reimbursement claim.

Free Superbill Template — Fill Out & Download Instantly

SUPERBILL / STATEMENT FOR INSURANCE REIMBURSEMENT

PROVIDER INFORMATION

PATIENT INFORMATION

SERVICE INFORMATION

DIAGNOSIS CODES (ICD-10)

SERVICES RENDERED

FINANCIAL SUMMARY

PROVIDER SIGNATURE

INSTRUCTIONS FOR PATIENT

What Is a Superbill Template?

When Do You Need It?

What's Included in This Template

How to Fill It Out

Legal Requirements & Notes

Frequently Asked Questions

Related Templates

Medical Bill / Patient Invoice

SOAP Note Template

HIPAA Business Associate Agreement (BAA)