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Section 11: The Superbill 

The superbill is a record of the financial transactions between the clinician and the client. One copy is provided to the client for his/her financial records and a duplicate copy is retained by the clinician. This document testifies that the clinician provided 1) professionally appropriate services; 2) the services that the client agreed to under the terms specified in the informed consent agreement (Statement of Understanding); and 3) services in accordance with other contractual agreements, such as contracts with insurance payers, providing only those services that are allowed and under conditions in which the services are permitted.

In order to meet these different professional obligations to both the client and the other parties, there are a number of items that need to be present on the superbill:

- The clinician’s name and legal business address(es)
- The date of the service
- The location of the service
- The name of the client
- The procedure code for services rendered (CPT Code)
- The diagnosis under which the client is being treated
- The charges for the service
- The co-payment for which the client is responsible
- Current balance owed to the clinician by either the client or the insurance payer
- Any unpaid previous balance owed to the clinician by the client

There are some additional items that are not necessary to meet the professional obligations of the superbill, but which are useful on a document of this nature:

- A reiteration of the payment and cancellation policies
- The date, time and location of the next scheduled appointment
- Clinician contact information: phone, cell phone, email, fax
- The clinician’s licensure number

A template for the superbill is shown below.


                                      Pat R. Clinician, LCSW

                                            Bill for Services

Date Charge Paid Balance Prev. Balance Client Name

 Procedure Code:                                                        DSM-5 Diagnosis:

____ 90791 Diagnostic Interview                               Diagnosis Code: _____
____ 90832 Indiv Psychotherapy 30 minutes           Diagnosis Code: _____ 
____ 90834 Indiv Psychotherapy 45 minutes           Diagnosis Code: _____ 
____ 90837 Indiv Psychotherapy 60 minutes           Diagnosis Code: _____ 
____ 90847 Family/couple Psychotherapy                Diagnosis Code: _____ 
____ EAP Session
____ ______ Other (List) __________________

 Date of next appointment: ___________ Time of next appointment: ____________
Location of next appointment: ____Somewhere ____Atlanta

*IMPORTANT NOTICE: Clients will be responsible for the full cost of all sessions missed or not cancelled with less than 24 hours notice. Insurance plans do not cover any costs for sessions missed or cancelled with short notice.

Atlanta Office:                                     Mailing Address:
220 Therapy Lane                              PO Box 800555
Atlanta, GA 30000                              Somewhere, GA 30099

Somewhere Office:                             Phone: (office) 404-555-7777
11 Rose Garden Pl.                            (cell) 770-555-5555
Somewhere, GA 30099                      (fax) 770-555-5556


GA License Number: CSW0000001