Penn Behavioral Health Services Out of Network Claim Form for 2026

1. Click ‘Get Form’ to open the Penn Behavioral Health Services Out of Network Claim Form in the editor.
2. Begin by filling in the Employee’s Name, Date of Birth, and Sex. Ensure that the mailing address and daytime phone number are accurate.
3. Indicate if there is a new address by selecting Yes or No. Provide an alternative phone number if applicable.
4. Enter the Social Security Number and ID Number, then circle your employer from the provided options.
5. Fill in the Patient's details including their name, date of birth, sex, relationship to employee, and social security number.
6. List the Provider’s information including name, daytime phone number, address, and degree/license.
7. Document each service received by entering dates, diagnosis codes (DSM IV), CPT codes, and charges for each entry. Attach itemized receipts as required.
8. Both Employee and Patient must sign at the bottom of the form to authorize release of information and certify accuracy.

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