Superbill

A superbill is an itemized receipt for care the patient has paid for. Patients submit it to their insurer for out-of-network reimbursement. Payment is the insurer's decision, so say so on the form. Fill it in from your own records and give it to the patient; nothing is entered on this site.

Practice	Name, address, phone
Clinician	Name and credentials, NPI, Taxpayer Identification Number
Patient	Name, date of birth, address
Insurance	Plan and member ID (the patient completes)
Date of service		Place of service code
Referring clinician	Name and NPI, if any

CPT or HCPCS code	Modifier	Description	ICD-10 code(s)	Units	Charge

Total charges		Amount paid	Date and method
Signature

This is a receipt for services paid in full. Submit it to your insurer for out-of-network reimbursement; payment is not guaranteed.

Colorado Care Network. Superbill. Version 2026-10-30.