Dr. Sarah Bennett, PsyD

Provider Info

INVOICE

  • Invoice Number: MED-2024-001
  • Date: April 29, 2026
  • Due Date: April 29, 2026
  • Terms: Due on Receipt

Patient Information

  • Patient Name: Jane Patient
  • DOB: April 11, 1985
  • Address: 789 Recovery Rd, San Francisco, CA 94110

Diagnosis Code (ICD-10)

  • F41.1 (Generalized Anxiety Disorder)
# Date CPT Description Qty Fee Amount
1 April 29, 2026 90837 Psychotherapy, 60 minutes 1 $180.00 $180.00
2 April 29, 2026 90847 Family Psychotherapy 1 $200.00 $200.00

Subtotal: $380.00
Total Due: $380.00
Amount in Words: Three Hundred Eighty Only

Provider Note

This document serves as a receipt for professional services rendered. It may be submitted to your insurance company for out-of-network reimbursement (Superbill).

Payment Method: Credit Card / FSA Card

This is a computer generated invoice; no signature required.

Superbills Made Simple

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What's a Superbill, Anyway?

It's the invoice your patient gives to their insurance company to get reimbursed for out-of-network care. Include CPT codes, diagnosis codes, and your NPI - insurance needs all of it.

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