Collect your online responses with Jotform and turn them into professional, elegant PDFs automatically.
Service Date | Procedure | Fee ($) | |
---|---|---|---|
1 | 01/02/2021 | Chest X-RAY, ECG, EEG, 2D ECHO | 5000 |
2 | 02/02/2021 | Monthly Check-up and prescription for maintenance | 200 |
3 | 03/02/2021 | Monthly Check-up and prescription for maintenance | 300 |
4 | 04/02/2021 | Monthly Check-up and prescription for maintenance | 200 |
5 | 05/02/2021 | Monthly Check-up and prescription for maintenance | 300 |
6 | 01/02/2022 | Chest X-RAY, ECG, EEG, 2D ECHO | 5000 |
7 | 01/02/2022 | Angiogram | 800 |
8 | 02/02/2022 | Stress test | 100 |
9 | 02/02/2022 | Chest X-RAY, ECG, EEG, 2D ECHO | 5000 |
10 | 03/02/2022 | Monthly Check-up and prescription for maintenance | 400 |
A superbill template is a standardized document that healthcare providers use to record details of patient visits and services rendered for the purpose of billing insurance companies. With a free superbill template from Jotform, you can outline details like the patient’s name, date of service, diagnosis codes, procedure codes, and charges for individual services. When you’re finished customizing your template, you can send the attached form directly to your providers and other team members for them to fill out on any device. Each response will then instantly be converted to a PDF and forwarded to your Jotform Inbox for safekeeping.
Want to make the superbill template your own? Our drag-and-drop form builder makes that easy. Feel free to add or edit form fields, drop in your own logo, adjust colors and fonts to match your branding, and more. You can even integrate with our 100+ apps — like Google Drive and Dropbox — to store your information in one place. Streamline the medical billing process, reduce errors, and improve office efficiency with a free superbill template from Jotform.
A superbill is used as the primary source of data on pricing and services rendered to create insurance claims. The superbill template serves as a quick reference guide for billing and coding, and helps healthcare providers collect patient information, health insurance details, procedure codes, medical diagnosis names, and details about the health provider — among other things.
All of this data is necessary to receive reimbursement from insurance companies, so it’s important that providers keep it accurate and organized for the best possible outcome. On top of that, the superbill template helps healthcare providers cut down on pesky paperwork and improve efficiency in their own billing process.
Yes. Superbills are used by medical professionals of all kinds, including physicians, pharmacists, physician assistants, and nurse practitioners. Requirements for superbills differ based on healthcare speciality and services, so there are a variety of superbill templates that can accommodate those needs.
When a healthcare practitioner is providing a generic service, such as a yearly checkup, the superbill is usually concise and straightforward. But superbills for specialists that provide more complex services will need to provide additional details, coding, and patient history — and thus will look very different.
Absolutely! With Jotform’s online form builder, you don’t need to know how to code to customize the superbill template. Just drag and drop to update your form fields for more details, change the design to match your brand, drop in your logo, or even add images for easy access.
If you require more than one physician signature, you can implement an automated signing order to immediately forward the document. Plus, sync your superbill template with our 100+ integrations for easy data analysis and storage.
The superbill template eliminates the need to code in order to build a superbill for your practice, ultimately boosting productivity and cutting down on time spent at the computer. Not only that, but the template streamlines your process by auto-generating PDFs that are ready to be sent to insurance companies and stored for later use.
Forget to add something the first time around? Not to worry — you’ll always have access to your submissions, and you can edit them at any time. Use a superbill template to smooth out your billing process and provide patients with the care they deserve.
In an emergency, you might not be able to effectively communicate about your full medical history with the paramedics. The Medical History Record PDF template means to provide the doctor patient's health history. With the help of the Medical History Record PDF template, the doctor will be able to ensure the patient's better care and treatment.By using this Medical History Record PDF template you can collect the patient's data such as personal information, contact information in an emergency case, questions about general medical history such as surgery, injuries, illnesses, allergies and medication that taken regularly. To help maintain HIPAA compliance, upgrade to an appropriate plan that supports HIPAA friendly features.
Provide your clinic or private practice’s patients with doctor’s notes they can send to their employers or professors. With this Doctor’s Note Template from Jotform Sign, it’s easy to create and customize professional doctor’s notes for any and all occasions. Include diagnosis, dates they won’t be attending work or school, contact info, and other important data.If you need to make some changes to your Doctor’s Note Template, all you need to do is open up our simple online form builder and drag and drop to personalize. Edit form fields to reflect new policies and contact information, upload branding and logos, create automated signing orders, and more. Get your patients on the mend quickly with this Doctor’s Note Template from Jotform Sign.
Every doctor wants to know their patients' medical histories. If you want to collect the medical history information and record these data as a pdf, Jotform will help you! First of all, you can use this medical history form template for gathering your patients' information for instance name, birth date, gender, height, weight, email, their drug allergies, illnesses, operations, medications, healthy & unhealthy habits such as a frequency of exercise, a frequency of alcohol consumption, a frequency of caffeine consumption and a frequency of smoking.Once you have collected these medical data, you can record them as a pdf by using this medical history PDF template. In addition, you can enhance the security of your forms by opting into one of our HIPAA friendly plans.
A medical invoice template is used by doctor’s offices, hospitals, and other healthcare organizations to show patients the costs they’ve incurred from medical visits. With this free Medical Invoice Template automatically generating PDF invoices for you, you can spend less time sorting out paperwork and more time caring for your patients. To get started, just fill in a short form with each patient’s treatments and costs. Once the form is submitted, a PDF invoice will be generated — easy to download or print for your records, or send to patients automatically with an autoresponder.Make this Medical Invoice Template match your organization’s needs by adding your unique logo, rearranging the design, and updating fonts and colors with our drag-and-drop PDF Editor. It takes just a few clicks to get the look you want! If you’d like to automatically send the invoice PDFs to other accounts — such as cloud storage accounts like Google Drive, Dropbox, or Box — do it automatically with Jotform’s 100+ free form integrations. Reduce manual data entry and speed up the invoicing process for your medical organization with this free online Medical Invoice Template.
A Vaccination Record Card is a document that servers as proof that an individual already received a vaccine from a health facility. Due to the COVID-19 pandemic, the government is requiring the citizens to receive vaccines as soon as they can be based on the provided schedule. If the citizen received a vaccine, there's a chance that it will minimize the spread of the virus or it will prevent the individual to be hospitalized due to bad conditions.This Vaccination Record Card PD template shows the name of the individual, age, date of birth, gender, batch number, patient number, vaccination record table, reminders, return date and time, and other important information. This PDF template is using the A5 paper size and the landscape layout so that it is more presentable and easy to read. This PDF template is using the Input Table tool in order to display the vaccination date, dosage, lot number, manufacturer, and the location where the patient received the vaccine. Customize freely this PDF template via the PDF Editor which is very easy to use.
Need a quick and professional way to verify patient pregnancies? Jotform’s got you covered. Create a Pregnancy Verification Template with Jotform Sign and add in personal patient details. Add clinic specific details, send out to patients, and gather signatures in just minutes. Send straight to your patients via link or embed in your online patient portal for quick reference.You can even customize your Pregnancy Verification Template to work for your clinic or hospital’s needs. Add additional form fields, change fonts and colors, create automated processes, and more. Once your patients acknowledge and sign this form, each party will receive a final copy for their records. Skip the messy paperwork and switch to Jotform Sign to verify patients pregnancies.
These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.