REQUEST FOR CLAIMS HISTORY REPORT FOR A FACILITY 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your facility information. Fill in the 'Facility Name', 'Street Address', 'City', 'State', and 'Zip Code' fields accurately.
3. Next, provide details about your insurance carrier. Complete the 'Insurance Carrier' section with the name, street address, and policy number.
4. In the designated area, ensure you include a detailed summary of all claims related to behavioral health or substance abuse treatment. If no claims have been filed, add a statement confirming this.
5. Sign the form in the 'Authorized Signature' section and date it appropriately. Make sure to print your name, title, and phone number for clarity.
6. Once completed, forward the form to your insurance carrier via email or fax as indicated.

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