Get Penn Behavioral Health Out Of Network Claim Form

Filling out the PENN Behavioral Health Out Of Network Claim Form is a crucial step in processing your claim for out-of-network benefits. This guide will walk you through the completion of the form, ensuring that you provide the necessary information accurately and efficiently.

Follow the steps to complete the claim form online with ease.

1. Click ‘Get Form’ button to download the PENN Behavioral Health Out Of Network Claim Form and open it in your preferred editor.
2. Begin by entering the employee’s name, date of birth, sex, and mailing address in the designated fields. Ensure that you include the daytime phone number and indicate if there is a new address.
3. Fill in the social security number and ID number as required, alongside the employer type (active, retired, or COBRA) and plan name.
4. Provide the patient's name, date of birth, sex, and their relationship to the employee. Also, include the patient's social security number and daytime phone number.
5. Enter the provider’s name, daytime phone number, fax number, and address, along with their degree or license.
6. Document the dates of service. For each date, include the corresponding diagnosis, CPT code, and charges for the service.
7. After completing the dates of service, indicate the date of the last appointment and provide a diagnosis and description of treatment in the designated area.
8. Both the employee's and patient’s signatures are required in the authorization section. Make sure to date the signatures as well.
9. Complete the certification section by confirming that all information provided is true and correct with the employee’s signature and date.
10. Once you have filled out the form completely, save your changes. You may now choose to download, print, or share the form for submission.

Complete your PENN Behavioral Health Out Of Network Claim Form online today!