Get Penn Behavioral Health Services Out Of Network Claim Form For ...

Filing an out-of-network claim can be a straightforward process when you have the right guidance. This guide outlines step-by-step instructions for filling out the Penn Behavioral Health Services Out Of Network Claim Form online, ensuring you provide all necessary information accurately.

Follow the steps to complete your claim form seamlessly.

1. Click ‘Get Form’ button to access the Penn Behavioral Health Services Out Of Network Claim Form and open it in your preferred document editor.
2. Begin by entering the employee's name, date of birth, sex, and mailing address in the designated fields. Additionally, include the daytime phone number and mark if the address has changed.
3. Input the necessary social security number and ID number, selecting the appropriate status — active, retired, or Cobra. Specify the plan name and circle your employer.
4. Fill in the patient’s details, including their name, date of birth, sex, relationship to the employee, social security number, and daytime phone number.
5. Detail the healthcare provider's name, contact number, and address. Provide their degree or license information.
6. In the services section, list the dates of service along with the corresponding diagnosis codes (DSM IV), CPT codes, and charges. Ensure all information is accurately filled out and itemized receipts are attached.
7. Gain signatures for the authorization to release information. Both the patient (or their guardian) and the employee must sign where indicated, including the date.
8. Review the entire form to ensure completeness and accuracy. Submit the claim form along with itemized bills via mail to the address provided in the form.
9. Keep copies of the completed form and all attached documents for your records. You can now save changes, download, print, or share your form as needed.

Start completing your Penn Behavioral Health Services Out Of Network Claim Form online today for a smooth reimbursement process.