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SuperBill
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Patient Name
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Patient Status
• • •
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Insurance Company
• • •
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Parent or Guardian Name
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Auth #
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PT.DOB:
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Start Date:
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Date of service:
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End Date;
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Appointment Time:
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QMHP
• • •
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Services
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Service Description
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Intake Part1 (min/hours)
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Day Treatment (min/hours)
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Intake Part 2: (min/hours)
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Psychosocial Rehabilitation (min/hours)
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Therapy (min/hours)
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Basic Skills Training (min/hours)
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Therapy Group (min/hours)
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I'm a second (min/hours)
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CASII/LOCUS (min/hours)
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Other (min/hours)
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Neurofeedback (min/hours)
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Others (min/hours)
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Axis 1 CTP Codes
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Billing Office Only
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Patient or Parent/Guardian Sign
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Default Diagnosis
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Provider Signature
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Amount to collect today
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Provider Printed Name
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Payment Type
• • •
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Payment Received By:
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Amount Paid
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2780 S.Jones Blvd.Suite 220 LV, NV 89146
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Phone 702-323-1323
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FORM 2015050
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Fax 702-405-6036
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