RTW Superbill Request Form
Please complete this form if you would like to request a Superbill for your completed and paid services.

A superbill is a document that contains information required by insurance agencies to provide you with reimbursement for out of pocket healthcare expenses.  It is important that you understand that Superbills contain sensitive HIPAA protected information and REQUIRES a diagnosis. Insurance interprets a diagnosis as proof of "medical necessity". We cannot guarantee reimbursement. 

Superbills will be emailed by the 10th of the month for the previous month and will include all dates within that month. Please understand that we cannot issue superbills for services that have not been paid. 

If your insurance carrier requires additional forms for reimbursement (ex: Aetna), please reach out to our billing department to coordinate.

240-571-2603
gigi@rootstowingstherapy.com
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Email *
Your Name *
Client's Name (person receiving services) *
Client's Date of Birth *
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DD
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How often would you like us to send you a superbill? *
Are there any specific dates of service you are requesting? (If not, we will provide info for sessions completed within the last 30 days .) *
Any other info you would like us to know about this request? *
We will email you the superbill. Please provide the email address. *
I understand that Superbills contain sensitive HIPAA protected information and REQUIRES a diagnosis. Insurance interprets a diagnosis as proof of "medical necessity". I also understand that RTW has no control  if and how much insurance will reimburse you and cannot guarantee payment by them. We cannot a provide a superbill for services that are left unpaid. *
A copy of your responses will be emailed to the address you provided.
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