NOTE: Date of service for any reimbursement older than 180 days will be denied for untimely filing.
INSTRUCTIONS: Attach the original or a copy of the bill or statement from the provider AND a receipt of payment with an EOB if applicable. Please keep a copy for your records. Make sure the bill contains all of the following information:
NOTE: The information listed below is usually provided on an itemized bill from the provider.
Patient's Full Name
The Date of Treatment
A Description of the Treatment (i.e. Therapy, Med. Management)
A Diagnosis (Type of Illness)
The Charge For Each Treatment
Place of Treatment (i.e. Provider's Office, Hospital
Sign This Form:
I, the undersigned, furnished the above information to enable American Behavioral to consider this claim for payment, and I certify that such information is true and correct and that the expenses were incurred by the above-named patient. I understand that any payment will be made to me.