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Important Notice
You may submit up to 5 files on one form, however, claims submitted under the same form will fall under the same submission ID. If you choose to inquire about your submissions we encourage you to submit claims individually. Thank you!
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MENTAL HEALTH SUBMISSION FORM
Please submit your claim(s) below. Thank you!
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Upload up to 5 PDF files per form
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W-9 (if not previously submitted)
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Do you have any progress notes or discharges papers to upload?
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Please upload any notes or discharge papers below:
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Would you like an email notification once your claim(s) have been processed?
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