superbillTEST — Concierge Sedation Associates

Superbill Request

Date of Service

See your receipt for this information

Location of Service

This is dentist's office name

Location of Service Address

This is the dentist's office address

Surgeon/Dentist's Name

Please contact your dentist's office for this information

Patient Name

Patient DOB

Patient Address

Parent/Guardian Name

Additional Diagnosis Code(s)

Check if applicable

F84.0 Autism

F90.2 ADHD

J45.909 Asthma

Top