Superbill Services
In most cases, we can help you get some of your money refunded from your health insurance provider after visits to cash-only clinics, or out-of-network providers. The amount returned is based solely on your insurance plan. We'll do the paperwork, you'll get the refund!

After submitting this form, one of our representatives will contact you to complete your enrollment. Please note we will require a front and back picture of your government issued ID.

Enrollment consists of a 30 minute phone call with you and your insurance provider to gather necessary information. There is a one-time $25 charge for this call. There is a charge of $2.50 plus shipping and handling for each superbill we submit on your behalf. By submitting this form, you agree to these charges.
Sign in to Google to save your progress. Learn more
Email *
Name *
Date of Birth *
Address *
Phone number *
Who is your Insurance provider? *
Please enter your Member ID *
Please enter your Group ID *
What is your insurers Customer Care phone number? *
How did you hear about us? *
By submitting this form, you agree to the charges outlined above. *
Required
Please enter your initials to indicate a signature: *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Consolidated Health Solutions. Report Abuse
Google Forms