Superbill Request Form
Thank you for trusting Ground to Overhead Physical Therapy with your healthcare!

If you would like the information necessary to file your appointment through your insurance company, please complete this form. If you do not complete this form, you will not receive the superbill for your visit!

After responding to the email, please allow 7-14 days for distribution of the superbill!
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Email *
Name: First and Last *
Your Email? *
Date of Visit *
MM
/
DD
/
YYYY
Physical Therapist Seen at Visit?  *
Was this your first visit? *
Which Describers your appointment *
In Person or Telehealth Visit? *
Discount received  *
(CHOOSE ONLY 1) Check the box which describes your problem the BEST *
Required
A copy of your responses will be emailed to the address you provided.
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