Client Superbill
An itemized superbill the practice completes and hands to the client, so they can file for out-of-network reimbursement with their own plan. Provider details, ICD-10 codes, service lines, and an attestation, all on paper.
Free. Updated August 2026.
What's on the form
Who fills it in
The front desk or biller completes every field before giving it to the client: provider and practice information, diagnosis codes, dated service lines with CPT codes and fees, and the payment summary. The client submits it to their insurance plan; the practice keeps the office-use copy.
Before you hand it out
The last page of the PDF is a note to the practice, with a reminder to remove it before the packet is copied or handed out. Review the form with your clinical leadership and counsel first, and adapt anything that does not match how your practice runs.
Looking for the guidance instead?
Superbill Template for Out-of-Network explains what a superbill must contain for a plan to accept it, and the mistakes that get them rejected. This is the blank superbill itself.
Read the full guide →