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Galaxy Diagnostics

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Superbill

Request a Superbill

How do I get a superbill for my insurance? Either fill out the form below with patient name, address, date of birth, date of service, tests ordered, ICD-10 codes, and the name of the ordering provider.
What tests were ordered?(Required)
Patient Name(Required)
Address(Required)
Superbill will be provided to this email. Please allow 2-3 business days for processing.
MM slash DD slash YYYY
MM slash DD slash YYYY
Date of service is the collection (or draw) date of the samples.
ICD-10 Codes(Required)
Please list out ALL of the ICD-10 codes that are given to you via your provider. What is an ICD-10 code? These are codes that are typically added to a requisition form by a provider that classify and record medical conditions, symptoms, or procedures.

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