Medical Wig Superbill Request

Medical Wig Superbill

THE HAIRCAREPRO LLC

This form is used to request an insurance reimbursement Superbill after your cranial prosthesis (medical wig) purchase or service has been completed. Submission of this form does not guarantee reimbursement. Coverage is determined by your insurance provider.

Provider Information

Provider Name: THE HAIRCAREPRO LLC
NPI: 1649120957
Service Type: Cranial Prosthesis ( Medical Wig )
CPT/HCPCS Code: A9282
Location of Service: In-office / Private Consultation

First name

Last name

Birthday

Month

Day

Year

Phone

Insurance Provider

List Diagnosis code/s and Prescriber

Purchase Amount Paid

Date of Service

Wig Purchased

I understand this is for reimbursement purposes only and

THE HAIRCAREPRO LLC/ Hair Extensions 614 does not communicate directly with insurance companies.

Signature

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Date

Month

Day

Year

I confirm the information provided is accurate to the best of my knowledge

What Happens Next

Once submitted, your Medical Wig Superbill will be reviewed and completed using the information provided and emailed to you within 2-3 business days. Reimbursement is determined by your insurance provider.