Doula Services
Superbill
Provider Information
Provider
Business
NPI
Tax ID / EIN
Address
Phone
Email
Client Information
Client Name
Date of Birth
Ins. Plan
Insurance ID
Address
Phone
Services Rendered
Date Code Description of Service Qty Unit Rate Total
Z1032 Extended Initial Visit90 minutes 1 $197.98 $
Z1034 Prenatal or Postpartum VisitPer visit · up to 8 visits $162.11 $
59409 Labor Support – Vaginal Delivery $685.07 $
59612 Labor Support – Vaginal DeliveryAfter previous Cesarean $768.69 $
59620 Labor Support – Cesarean Section $795.73 $
T1033 Support During or After Miscarriage $250.85 $
59840 Support During or After Abortion $250.85 $
T1032 Extended Postpartum VisitUp to 2 visits · 3 hrs each $486.36 $
Z1038 Additional Postpartum VisitUp to 9 visits $162.11 $
Total Charges Due
$
Certifications

I certify that the services listed above were provided to the client identified, and that the information is true and correct to the best of my knowledge.

Provider Signature
Date

I acknowledge receipt of the services listed above. (Optional)

Client Signature
Date
Notes for Client
  • Submit this superbill along with your insurance plan's Member Claim Form for potential reimbursement.
  • Keep a copy for your records.
  • Reimbursement is not guaranteed — confirm coverage directly with your insurance plan.
Confidential Client Document
Doula Services Superbill