Insurance · Sample
A sample superbill.
An example of the itemized superbill we provide after an eligible visit. Submit it to your insurer to seek out-of-network reimbursement — we don’t bill insurance directly. Codes shown are illustrative; your physician confirms the codes for your specific visit.
SuperbillFor insurance reimbursement
An itemized statement for submitting to your insurer for out-of-network reimbursement. TickDoc does not bill insurance directly.
Provider
Rendering provider
Adam Z. Kawalek, MD
Adam Z. Kawalek, MD
NPI
1326223306
1326223306
Tax ID (EIN)
—
—
Practice
SickSlip, P.A.
SickSlip, P.A.
Place of service
02 · Telehealth
02 · Telehealth
Patient
Name
Sample Patient
Sample Patient
Date of birth
Jan 1, 1985
Jan 1, 1985
Date of service
July 13, 2026
July 13, 2026
Reference
DEMO1234
DEMO1234
| Code | Description | Charge |
|---|---|---|
| Z20.89 ICD-10 Dx | Contact with and (suspected) exposure to other communicable diseases | — |
| W57.XXXA ICD-10 Dx | Bitten/stung by nonvenomous insect and other nonvenomous arthropods, initial encounter | — |
| 99422 · 95 CPT | Online digital evaluation & management, established patient, 11–20 min | $49.00 |
| Total charged / paid | $49.00 |
Adam Z. Kawalek, MD · NPI 1326223306