Price: $15.00
Format: Editable PDF | 1 Page | Instant DownloadDescription:
Protect your practice from insurance-related disputes and privacy risks with this clear, client-signed acknowledgment form. The Superbill Opt-Out Request documents when a client chooses not to receive superbills or insurance documentation containing CPT or diagnosis codes—keeping your practice compliant and transparent.Includes:
Clear statement of client’s voluntary opt-out
Explanation of superbills, CPT, and diagnosis codes
Acknowledgment of private pay and reimbursement waiver
Signature and date fields for documentation
Fillable, editable PDF format with GBBS branding
Perfect for:
Therapists, psychiatrists, and group practices wanting a clear, compliant way to document client agreement to payment terms.
* Created by Golden Bee Billing Services, LLC — experts in behavioral health billing, compliance, and operational design.
Taxes included in price.
Superbill Opt-Out Request Form (2025 Edition)
© 2025 Golden Bee Billing Services, LLC
All rights reserved. This document is an original work created by Golden Bee Billing Services, LLC and may not be copied, resold, or distributed without written permission.This template is intended for informational and administrative use only. It does not constitute legal advice and should be reviewed or customized to fit your individual practice policies and state regulations before use.
Licensing Your purchase includes a single-use commercial license for use within one private practice. You may print, fill, and digitally store the form for client use within your practice, but redistribution, resale, or reproduction for others is not permitted.
Pricing Note All prices listed in The Hive Shop include applicable taxes. No additional fees will be added at checkout.