Signed in as:
filler@godaddy.com
Signed in as:
filler@godaddy.com
Please complete the Patient section and email it to me. I will complete the remaining sections and return to you for your signature.
You can then submit this form to your insurance or HSA/FSA.
Superbill Template (pdf)
DownloadA SuperBill is an itemized receipt that includes information needed by insurance companies for out of network reimbursements. I am happy to provide a SuperBill to you on a quarterly or semi-annual basis so that you can request reimbursement for your therapy payments. SuperBills can also be used to document payments made from a health or flexible spending account (HSA/FSA). Important: it is your responsibility to determine what benefits are offered by your insurance carrier for out of network providers.
Copyright © 2024 Heather Koledo Online - All Rights Reserved.
Powered by GoDaddy
We use cookies to analyze website traffic and optimize your website experience. By accepting our use of cookies, your data will be aggregated with all other user data.