Superbill Request

Lake Arrowhead Acupuncture & Holistic Health

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Request Your Superbill ‚Äî Arrowhead Acupuncture

ARROWHEAD ACUPUNCTURE
& INTEGRATIVE EASTERN MEDICINE

Request Your Superbill

Fill out the form below and your superbill will be emailed to you within one business day. For questions, call 909-485-0118.

Patient Information

Full Name

Date of Birth

Email Address

Date(s) of Service

Treating Provider

Provider

Diagnosis (ICD-10) - select all that apply

M54.50Low back pain, unspecified M54.51Vertebrogenic low back pain M54.2Neck pain M54.6Thoracic spine pain M54.41Sciatica, right M54.42Sciatica, left M25.511Shoulder pain, right M25.512Shoulder pain, left M25.331Wrist pain, right M25.332Wrist pain, left M79.641Hand pain, right M79.642Hand pain, left M25.561Knee pain, right M25.562Knee pain, left M25.371Ankle pain, right M25.372Ankle pain, left M79.671Foot pain, right M79.672Foot pain, left R51.9Headache, unspecified G43.909Migraine, unspecified

Services Received (CPT) - select all that apply

99202Initial evaluation ($25) 97810Acupuncture, initial 15 min 97811Acupuncture, add'l 15 min 97813Acupuncture w/ e-stim, initial 97814Acupuncture w/ e-stim, add'l 97010Heat/cold packs 97026Infrared therapy 97016Cupping 97124Massage 97110Therapeutic exercise 97140Manual therapy techniques

Payment

Total Amount Paid ($)

Your superbill will be emailed to you within one business day.
Questions? Call 909-485-0118.

✓ Request received! Your superbill will be emailed to you within one business day.
Thank you for choosing Arrowhead Acupuncture.

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Request Your Superbill

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