• 770-313-7768
  • melissa@melissalesterlcsw.com

Superbill

Client Superbill Instructions

Please complete all fields in RED and submit form. Superbills are reviewed and returned on Mondays.


SUPERBILL – REIMBURSE CLIENT ONLY

************************************************************
MM slash DD slash YYYY
____________________________________________________________
MM slash DD slash YYYY
____________________________________________________________
MM slash DD slash YYYY
____________________________________________________________
MM slash DD slash YYYY
____________________________________________________________
MM slash DD slash YYYY
____________________________________________________________
MM slash DD slash YYYY
____________________________________________________________
MM slash DD slash YYYY
____________________________________________________________
MM slash DD slash YYYY
____________________________________________________________
MM slash DD slash YYYY
____________________________________________________________
MM slash DD slash YYYY
____________________________________________________________
MM slash DD slash YYYY
____________________________________________________________
Reset signature Signature locked. Reset to sign again
MM slash DD slash YYYY

© melissalesterlcsw.com 2023

error: Content is protected !!