Request a Superbill from Good Mental Health
Email: office@GoodMentalHealthLLC.com, Call: 904-325-6105, or submit your request using this form. Please note: we cannot guarantee reimbursement as an out-of-network provider.
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Client Name *
Client Date of Birth *
Client's Mailing address *
Client's telephone number *
Client's email address *
Name of Insurance Provider *
Member ID Number *
Group Number *
Date of Request *
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Last 4 digits of Client's Social Security Number *
Please allow 5-7 business days for your request to be completed.  Would you prefer your document to be returned via email or U.S. Postal Service? *
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