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Out of Network Claim Form for Members - Penn Behavioral Health 2026
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- Click ‘Get Form’ to open the Out of Network Claim Form in the editor.
- 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.
- Indicate if there is a new address by selecting Yes or No. Provide an alternative phone number if applicable.
- 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.
- Fill in the Patient’s details including their name, date of birth, relationship to employee, and daytime phone number.
- List the Provider’s information including their name, contact details, and degree/license. Document all services received with corresponding dates and diagnoses.
- Complete the CPT codes and charges for each service provided. Ensure that you are using the updated CPT codes as required.
- Both Employee and Patient must sign at the bottom of the form to authorize release of information and certify accuracy.
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Related links
(a) For claims with a new provider, please preregister by contacting Penn Behavioral Health Corporate Services at. 888-321-5533. (b) Complete this formRead more
Seeing an out-of-network doctor for physical services, but not behavioral health services; Your insurance company says it will not pay for behavioral healthRead more
Nov 19, 2024 Evaluate and treat undiagnosed physical and mental health issues. Network (CPEN): Health care professional organization for sharing experiences