Superbill/Invoice (Complementary & Integrative Medicine Visit)

Superbill / Itemized Invoice

Complementary & Integrative Medicine Visit

Invoice ID: [Invoice ID]
Issue Date: [Issue Date]
Status: [Draft / Final / Corrected / Void]
(If Status is Corrected, include: Original Invoice ID: [Original Invoice ID]; Correction Reason: [Brief correction reason])

(Use YYYY-MM-DD for all dates. Use two-decimal currency formatting for all amounts. For Final documents, omit empty fields and entire sections with no data; for Draft documents, placeholders are acceptable.)

Patient Information

• Full Legal Name: [Patient full legal name]
• Date of Birth: [Date of birth]
• Patient Account/Chart #: [Account or chart number]
• Address: [Patient mailing address] (Include only if provided)
• Contact: [Phone and/or email] (Include only if provided)

Practice & Provider Information

Billing Practice

• Legal Practice Name: [Practice legal name]
• Billing Address: [Street, city, state, ZIP]
• Phone: [Practice phone]
• Tax ID: [EIN / SSN] [Tax ID number]
• Organizational NPI (Type 2): [Type 2 NPI] (Include when applicable)

Rendering Provider

• Name: [Provider full name with credentials as licensed]
• Provider Type/Specialty: [Provider type] (Use explicit labels such as Naturopathic Physician, Licensed Acupuncturist, Certified Health Coach; do not substitute categories)
• License: [License type] — [State] [License number]
• Individual NPI (Type 1): [Type 1 NPI] (Include when applicable)

Encounter Summary

• Date(s) of Service: [Service date or date range]
• Service Location: [Physical address / Telehealth]
• Place of Service: [POS code] - [POS descriptor] (e.g., 11 - Office; include when known)
• Service Modality: [In-person / Telehealth synchronous video / Telehealth audio-only / Group visit / Home visit]

Itemized Services

(Include procedure codes and diagnosis pointers only when explicitly provided—do not infer codes from service descriptions. Use letters A, B, C… in Dx Pointer to map to the Diagnoses section.)

Date of Service	Service Description	Procedure Code (CPT/HCPCS)	Modifiers	Units	Dx Pointer	Unit Charge	Line Total
[Date]	[Patient-friendly service description]	[Procedure code] (Leave blank if not provided)	[Modifier(s)] (If applicable)	[Units]	[A / B / C / …] (Include only if diagnoses are listed)	[Amount]	[Amount]

(Repeat rows for each additional service. If no procedure codes are present on any service line, add: "Procedure codes not included. Some payers require codes for reimbursement.")

Retail Products (Non-Reimbursable)

(Include this section only if retail items such as supplements or devices were sold during the visit.)

Date	Product Description	Item Code/SKU	Quantity	Unit Price	Line Total
[Date]	[Product name and strength/size if applicable]	[Item code/SKU] (Optional)	[Quantity]	[Amount]	[Amount]

(Repeat rows for each additional retail item.)

Diagnoses

(List only diagnoses addressed during this encounter in priority order. Assign pointer letters A, B, C… corresponding to the Dx Pointer column above.)

• [A] [Diagnosis name] — [ICD-10-CM code] (Include code only if provided)
• [B] [Diagnosis name] — [ICD-10-CM code]

(Add additional diagnosis lines as needed. If diagnoses are intentionally omitted, instead display: "Diagnosis information not provided on this document.")

Totals

• Subtotal: [Amount]
• Discounts/Adjustments: [Description and amount] (Include only if applicable)
• Total Charges: [Amount]
• Payments Received: [Amount] — [Payment date/reference] (Include only if payments made)
• Amount Due: [Amount]

(If Amount Due is zero, display: Paid in Full — [Receipt/transaction reference])

Provider Attestation

(Include this section only when Status is Final and intended for payer submission. Omit for Draft or Void documents.)

[Signature on file / Provider signature]

Rendering Provider: [Provider full name with credentials]

Attestation Date: [Date]

Disclaimers

• This superbill is provided for your records and may assist with out-of-network reimbursement requests; reimbursement is not guaranteed and depends on your plan.
• Patient remains responsible for charges regardless of payer determination.
• Some complementary and integrative services may be considered non-covered or wellness-oriented by certain plans.