superbill request for reimbursement purposes Name * First Name Last Name Email * Beginning Date of Service * MM DD YYYY Other Family to Include When Will You Need This By? Anything Else? HIPAA Consent * Dear Patient, I hope this message finds you well. As part of our efforts to streamline your care, we can send your superbill to you via email. Please be aware that this may include sensitive information related to your health (PHI). While we take every precaution to ensure the security of your information, email is not always a completely secure method of communication. By agreeing to receive your superbills this way, you acknowledge the risks and consent to this delivery method. Let us know if you prefer an alternative method (such as postal mail or in-office pick-up). If you have any questions or concerns, feel free to reach out. Thank you for your time and understanding. Warm regards, BetterRoots Family Chiropractic. I understand and accept Thank you!We will get back to you within 1 to 3 business days.
