Reimbursement Claim Form

Reimbursement Claim Form
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Provider Information
Practice/Facility
Phone Number

Area CodePhone Number
Treating Provider

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Treatment Information
Service Rendered

Outpatient TherapyGroup TherapyInpatient Mental Health TreatmentIntensive Outpatient ProgramOther
Procedures*
Attach Superbill or Final Statement

Browse Files

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I confirm that the amount due requested for reimbursement reflects the net amount due after any payments received or expected from insurance, Medicare, or Medicaid have been applied.

I hereby declare, under the penalty of perjury of the laws of the United States that the information I provided above is true and correct to the best of my knowledge.
Name

First NameLast Name
Signature

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Date Signed

MonthDayYear
Date
Should be Empty:

Provider Information