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It details patient information, provider details, diagnosis, and procedures. Specifically, it lists two procedures: '3D Areola Tattooing of RIGHT breast to correct color defects of skin' and '3D Areola Tattooing of LEFT breast to correct color defects of skin', both utilizing CPT code 11921 and ICD-10-CM C50.011 and C50.012 respectively. The superbill also includes fields for date, invoice number, patient name, address, phone, DOB, place of service, and EIN. It outlines payment terms as 'Due On Receipt' and has a designated area for the due date. The technician is identified as Laura Cavalcanti. The form is designed to bill for medical tattooing services, particularly focused on areola reconstruction and color correction.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/superbill-template-the-medical-tattoo-and-medical-tattoo-denver-website/189498/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/superbill-template-the-medical-tattoo-and-medical-tattoo-denver-website/189498.png","ImageObject",442,249,{"name":88,"@type":89},"Eden","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-27","2026-09-03",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What services are being billed on this superbill?","Question",{"text":108,"@type":109},"The superbill is for 3D Areola Tattooing of both the right and left breasts to correct color defects of the skin, using CPT code 11921.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Who is the healthcare provider listed on this superbill?",{"text":113,"@type":109},"The provider is The Medical Tattoo, with Laura Cavalcanti listed as the Restorative Technician.",{"name":115,"@type":106,"acceptedAnswer":116},"What are the payment terms for this superbill?",{"text":117,"@type":109},"The payment terms are 'Due On Receipt', meaning the payment is expected upon receiving the bill.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},189498,1788397388,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":4},1374391974468,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","| Date:\u003Cbr>Invoice \\#:\u003Cbr>Provider:\u003Cbr>Address:\u003Cbr>Phone:\u003Cbr>Place of Service:\u003Cbr>EIN: | SUPERBILL\u003Cbr>The Medical Tattoo Patient Name:\u003Cbr>13840 Box Turtle Loop Patient Address: Parker, CO 80134\u003Cbr>(303) 621-4711 Patient Phone: IN OFFICE Patient DOB:\u003Cbr>93-4956038 |  |  | |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| PATIENT |  |  | DIAGNOSIS |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n| RESTORATIVE TECHNICIAN |  |  | PROCEDURE |  | PAYMENT TERMS |  | DUE DATE |\n| LAURA CAVALCANTI – The Medical Tattoo |  |  |  |  | Due On\u003Cbr>Receipt |  |  |\n|  |  |  |  |  |  |  |  |\n| DATE OF SERVICE | BILLING CODE | DESCRIPTION |  | UNIT PRICE |  | LINE TOTAL |  |\n|  | ICD-10-CM C50 .011 CPT 11921 | 3D Areola Tattooing of RIGHT breast to correct color defects of skin |  |  |  |  |  |\n|  | ICD-10-CM C50 .012 CPT 11921 | 3D Areola Tattooing of LEFT breast to correct color defects of skin |  |  |  |  |  |\n| Total Due |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |\n|  |  |  | TOTAL PAID:\u003Cbr>TOTAL DUE: |  |  |  |  |","cbCaid6ixgBfZ4nW","https://ap.wps.com/l/cbCaid6ixgBfZ4nW","pdf",142931,"English","# Patient Information\n# Provider Information\n# Diagnosis and Procedures\n# Billing and Payment Terms","[{\"question\":\"What services are being billed on this superbill?\",\"answer\":\"The superbill is for 3D Areola Tattooing of both the right and left breasts to correct color defects of the skin, using CPT code 11921.\"},{\"question\":\"Who is the healthcare provider listed on this superbill?\",\"answer\":\"The provider is The Medical Tattoo, with Laura Cavalcanti listed as the Restorative Technician.\"},{\"question\":\"What are the payment terms for this superbill?\",\"answer\":\"The payment terms are 'Due On Receipt', meaning the payment is expected upon receiving the bill.\"}]","Superbill-Template-The-Medical-Tattoo-and-Medical-Tattoo-Denver-Website | PDF"]