Get Beacon Mental Health/substance Abuse Treatment Claim Form

This guide provides a clear and supportive overview of the process for filling out the Beacon Mental Health/Substance Abuse Treatment Claim Form online. It includes step-by-step instructions designed to assist users in completing each required field of the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the Beacon Mental Health/Substance Abuse Treatment Claim Form and open it in your preferred online editor.
2. Begin with Part I of the form, which you, as the patient or employee, must complete. Ensure that you fill in all fields marked in bold lettering, as these are mandatory for processing your claim.
3. In the 'Patient's Name' field, enter the patient's full name as it appears on their identification card, including Last, First, and Middle Initial.
4. Provide the patient’s permanent address, including Street, Apartment/PO Box Number, City, State, and Zip Code in the respective fields.
5. Enter the patient’s ID number, which is a 9-digit number for subscribers or an 11-digit number for dependents, as shown on their insurance ID card.
6. Complete the patient’s birth date by entering the Month, Day, and Year of birth.
7. Indicate the patient's sex by placing an X in the appropriate box (Male or Female).
8. Specify the patient’s relationship to the subscriber by selecting the correct option.
9. If the patient is a dependent, provide the employee's name and Social Security Number as necessary. Include the employer’s name and group number if available.
10. Answer question 9 about coverage by other group insurance plans by placing an X in the appropriate box and provide all requested information if applicable.
11. Complete the Medicare eligibility section by indicating if the patient is eligible, and if so, provide the effective dates for both Part A and Part B.
12. Confirm whether the provider has been paid for services by selecting Yes or No. If selecting Yes, include the amount paid in Part II.
13. If benefits should be directed to the provider, sign the authorization section where indicated.
14. Provide your signature and date in the patient/subscriber's signature section to certify the information is accurate.
15. Ensure that the attending provider completes Part II of the form, including all necessary fields and signatures.
16. Finally, save your changes, and choose to download, print, or share the completed form as needed.

Complete your Beacon Mental Health/Substance Abuse Treatment Claim Form online to ensure a smooth claims process.