Follow the steps to effectively complete the form.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering the facility name in the designated field. This should be the legal name of the facility requesting the claims history report.
3. Next, fill in the street address of your facility. Ensure accuracy to prevent any delays in processing.
4. Provide the city where the facility is located. This helps in identifying the jurisdiction of the facility.
5. Enter the state in which the facility resides. This should correspond to the city information provided.
6. Add the zip code for the facility’s address. This ensures precise location identification.
7. Now, fill in the insurance carrier's name. This is critical as the claims history will be sent to this carrier.
8. Provide the street address of the insurance carrier. This information is necessary for the completion of the report.
9. Include the policy number associated with the facility. This helps to link the claims history with the correct policy.
10. In the notes section, indicate that the report must detail all claims related to behavioral health or substance abuse treatment, including the date, current status, and settlement amount of each claim.
11. If no claims have been filed during the requested time period, please ensure to note that by including a statement to that effect.
12. Sign the form in the designated area, authorizing the insurance carrier to forward the requested information directly to MHC.
13. Print your name and title to clearly identify who is completing the form.
14. Finally, provide a phone number for any follow-up questions related to this request.
15. Once all fields have been filled correctly, review the document for any errors, and then proceed to save your changes, download, print, or share the completed form as needed.

Complete your PA MHC Request For Claims History Report For A Facility online today to ensure timely processing of your claims history.