Follow the steps to successfully fill out the Beacon Health Printable Void Form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the demographic information section. Provide the provider name, provider ID number, member name, member ID number, Beacon invoice number, the date the Beacon invoice was paid, and the contact person's name along with their telephone number.
3. Move to the reason(s) for adjustment/void section. Here, check all that apply for the requested action, including adjustment, void, decrease payment, or increase payment.
4. In the reason subsection, indicate any specific issues by checking the appropriate boxes. Common reasons include incorrect member ID, incorrect date of service, incorrect units, incorrect amount, incorrect procedure or modifier, or if authorization was extended. If selecting 'Other,' please provide an explanation.
5. Provide your signature as the provider, along with the date you are submitting the form.
6. The form has a section designated for Beacon use only. While you do not need to fill this out, be aware that it includes status options such as approved or denied along with the processor's name and processing code.
7. Once the form is completed, save your changes. You can then choose to download, print, or share the filled-out document as needed.

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