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SUBSTANCE ABUSE SUBMISSION FORM
Please read the instructions below to ensure correct processing and payment
INTENSIVE OUTPATIENT
Submit claims in increments of 13 days/units as authorized
PARTIAL HOSPITALIZATION
Submit claims in increments of 24 days/units as authorized
INPATIENT RESIDENTIAL
Submit claims in increments of 28-30 days/units as authorized
Important Notice
You may submit up to five files on one form, however, claims submitted under the same form will fall under the same submission ID. If you wish to inquire about your submissions we encourage you to submit claims individually. Thank you!
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SUBSTANCE ABUSE CLAIM FORM
Please submit your claim(s) below. Thank you!
Time
Hour Minutes
AM
PM
AM/PM Option
Date
-
Month
-
Day
Year
Date
Upload claims below:
*
Browse Files
Drag and drop files here
Choose a file
Maximum of 5 PDF files accepted
Cancel
of
Please upload a W-9 form below if one has not been submitted this year:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have any treatment summaries or discharge papers to upload?
Yes
No
Please upload any treatment files/ discharge papers below
Browse Files
Drag and drop files here
Choose a file
Maximum of 5 files
Cancel
of
Would you like an email notification once your claims have been processed?
*
Yes
No
Please provide your email below
example@example.com
Submit
IMPORTANT
All emails sent from Beat It! are encrypted to ensure compliance with HIPAA laws
Should be Empty: