Out of Network Claim Form for Members - Penn Behavioral Health 2026

1. Click ‘Get Form’ to open the Out of Network Claim Form in the editor.
2. Begin by filling in the Employee’s Name, Date of Birth, and Sex. Ensure that you provide the correct mailing address and daytime phone number.
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, along with the Plan Name and your employer's name by circling either UPHS or University of Pennsylvania.
5. Fill in the Patient’s details including their name, date of birth, relationship to employee, and daytime phone number.
6. List the Provider’s information including their name, contact details, and degree/license. Document all services received with corresponding dates and diagnoses.
7. Complete the CPT codes and charges for each service provided. Ensure that you are using the updated CPT codes 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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