Mental Health / Substance Abuse Treatment Claim Form
DIRECTIONS FOR COMPLETION
In order to facilitate payment of this claim, please be sure that all parts are completed in their entirety. An
explanation of each field is provided below. The fields in BOLD lettering are required in order for the claim
to be considered for payment.
If you are unable to complete the provider signature portion of the form, please print their name in Box 7,
Part II. Please be sure that as much of Part II is completed as possible. Y
Please make every effort to have this form printed in red ink. Please use a black ballpoint pen when filling
in the required fields. This allows the claim to be scanned through technology that expedites the claims
payment process. (However, black and white forms are accepted.)
PART I: (Required fields are in BOLD lettering)
1. PATIENT’S NAME – Enter the Patient’s name (Last, First Name, and Middle Initial). Spell the name
exactly as it appears on the subscriber/patient’s identification card.
2. PATIENT’S ADDRESS – Enter the Subscriber/Patient’s permanent address (Street, Apartment/PO Box
Number, City, State, Zip Code).
3. PATIENT’S ID NUMBER – Enter the Subscriber/Patient’s 9-digit ID number, or in the case of a
dependent, the 11 digit ID number. This number appears on the Patient’s insurance ID card.
Note: If this item is blank, the claim will be returned for this information.
4. PATIENT’S BIRTH DATE – Enter the Patient’s date of birth.
5. PATIENT’S SEX – Put an X in the appropriate box to indicate the Patient’s sex.
6. PATIENT RELATIONSHIP TO SUBSCRIBER – Put an X in the appropriate box to indicate the Patient’s
relationship to the Subscriber.
7. EMPLOYEE’S NAME – If different than Patient.
8. EMPLOYEE’S SOCIAL SECURITY NUMBER – Enter the Subscriber’s Social Security Number (SSN) or
8a. EMPLOYER NAME/GROUP NUMBER – Enter the Subscriber’s Employer name. If the Employer’s
group number is available on the card, please also provide.
OTHER MENTAL HEALTH/SUBSTANCE ABUSE COVERAGE
(This information is important if the Patient is covered under other group insurance. Even if the Patient is not
covered under other group insurance, please answer question #9.)
Adapted fom: Beacon Health Services and the CMS1500805 and HCFA 1500 forms
9. IS THE PATIENT COVERED BY ANY OTHER GROUP INSURANCE PLAN? – Put an X in the
If there is no other insurance coverage, you do not have to answer the following questions:
• NAME OF OTHER INSURANCE COMPANY
• CARD NUMBER – This is the identification number assigned to the Subscriber by the other insurance
• ADDRESS OF OTHER INSURANCE COMPANY – Enter address of the other insurance carrier as it
appears on the identification card.
NOTE: The other insurance carrier must be billed for these services. When you receive the Explanation of
Benefits from the other insurance carrier, you should attach it to this claim form. Attach it even if the other
insurance carrier does not pay anything on the services.
10. MEDICARE ELIGIBLE – Place an X in the appropriate box.
If “Yes” complete the following:
PART A – EFFECTIVE DATE – Month, Day and Year
PART B – EFFECTIVE DATE – Month, Day and Year
ASSIGNMENT OF BENEFITS
(This information is very important to assure any payment on the claim goes to the appropriate party, either to the
member or the provider.)
11. HAS THE PROVIDER BEEN PAID – Put an X in the appropriate box. If you answer “Yes” to this
question, please make sure that the amount paid is recorded in Box 9, Part II, Amount Paid.
11a. AUTHORIZATION TO PAY PROVIDER – The Subscriber should sign here if the provider is to be paid
directly by the Insurance Company. This should be signed by the Patient. If the Patient is an underage dependent,
this should be signed by the Subscriber. If you have paid the Provider for these services, do not sign this
12. PATIENT/SUBSCRIBER’S SIGNATURE – This item must be signed by the Patient or Subscriber as
verification that the services were rendered by the Provider listed on the form, and as authorization to release
PART II: (Required fields are in BOLD lettering)
Note: If this form is not completed, claim form will be returned to the provider.
The company must have a current 1099 on file for the address to which this claim will be paid (box 12) . I
1. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE – The name and license level of the referring
physician should be provided here. If you are the physician providing the service but you are not the referring
physician, enter the name of the referring physician here. Leave blank if no referring physician.
2. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED
3. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? – Check appropriate box.
4. DIAGNOSIS – All claims must contain a medically accepted diagnosis. Enter a valid ICD-10-CM or DSM- 5
diagnosis code (including the fourth and fifth digits if applicable) that describes the principal diagnosis for the
services rendered. There can be up to 3 diagnoses indicated. The primary diagnosis should be listed first.
5. CONDITION RESULTING FROM:
CURRENT EMPLOYMENT – Place an X in the appropriate box.
ACCIDENT AT WORK – Place an X in the appropriate box.
6. INFORMATION PERTAINING TO THE VISIT:
A. DATE OF SERVICE – Enter the “From” and “To” dates of service in MM/DD/YY (ex: 06/04/04)
format. Claim line items can include no more than two dates of service for the same procedure code,
unless the days are consecutive and the units coincide. Enter the number of units in 6F.
B. PLACE OF SERVICE – Enter the appropriate place of service code. A table of the valid codes is
provided on the following page (see Attachment A).
C. PROCEDURE CODE – Enter the procedures, services, or supplies using most current CPT-4 or HCPCS
codes, including modifiers, if any are necessary.
D. EXPLANATION OF SERVICES – This is the written description of the service/procedure indicated in
E. DIAGNOSIS CODE – Refer to the diagnosis entered in Box 4, Part II and indicate the most appropriate
diagnosis for each procedure by using either 1, 2 or 3.
F. DAYS OR UNITS – Enter the number of services billed. For anesthesia, show the elapsed time in
G. CHARGES – Enter your usual or customary charge for the service/procedure rendered as indicated on
7. SIGNATURE OF PHYSICIAN/SUPPLIER & DATE – Signature of Physician or Supplier including degree(s)
or credentials and Date of Signature for the Provider rendering service. The actual signature, signature stamp or
computer-generated signature of the physician is preferable. If you are unable to obtain this, please print the name
of the Provider in this field.
8. TOTAL CHARGE – Enter the total charge for this claim. This is the total of all the charges for each service
noted in Box 6G, lines 1-6.
9. AMOUNT PAID – If the answer to Box 9, Part I is “Yes”, the amount paid by the other insurance carrier
should be indicated in this block. The Explanation of Benefits from the other insurance carrier needs to be attached
to the claim. If the Patient has paid for the charges being submitted on this claim form, please indicate the amount
paid in this block.
10. BALANCE DUE – Enter the balance due for services listed on the claim form.
11. PROVIDER FEDERAL TAX ID NO. – Enter the Provider’s 9-digit employer identification number (EIN) or
social security number (SSN) under which payment for services is to be made for reporting earnings to the IRS. If
the claim is to be paid to the Patient, the information in this field is not needed.
12. PHYSICIAN’S OR MEDICAL ASSISTANCE SUPPLIER’S NAME, ADDRESS, ZIP CODE AND
TELEPHONE NUMBER & PROVIDER ID NUMBER – Enter the Provider’s name, address, and telephone
number. If applicable, please include the Insurance provider identification number.
13. PATIENT’S ACCOUNT NO. – Enter the unique number assigned by the Provider for the Patient.
Mental Health / Substance Abuse Treatment
PART I TO BE COMPLETED BY EMPLOYEE/PATIENT
1. PATIENT’S NAME (LAST) (FIRST) (MIDDLE INITIAL)
2. PATIENT’S ADDRESS (STREET) (CITY) (STATE) (ZIP CODE)
3. PATIENT’S ID NUMBER (ON YOUR INSURANCE ID CARD)
4. PATIENT’S BIRTHDATE 5. PATIENT’S SEX
6. PATIENT’S RELATIONSHIP TO SUBSCRIBER
MONTH DAY YEAR SELF SPOUSE CHILD
7. EMPLOYEE’S NAME (LAST) (FIRST) (MIDDLE INITIAL)
8. EMPLOYEE’S SOCIAL SECURITY NUMBER 8a. EMPLOYER NAME / GROUP NUMBER
OTHER MENTAL HEALTH OR SUBSTANCE ABUSE COVERAGE:
9. IS THE PATIENT COVERED BY ANY OTHER GROUP INSURANCE PLAN? YES NO
NAME OF OTHER INSURANCE COMPANY : ID NUMBER:
ADDRESS OF OTHER INSURANCE COMPANY
10. IS THE PATIENT ELIGIBLE FOR MEDICARE? YES NO
MEDICARE PART A
MONTH DAY YEAR MEDICARE PART B
MONTH DAY YEAR
If the patient is covered under any other insurance, attach a copy of any bill(s) submitted to the carrier and an Explanation of Benefits.
ASSIGNMENT OF BENEFITS:
11. HAS THE PROVIDER BEEN PAID FOR THESE SERVICES? YES (If yes, do not sign 11a) NO, (If no, go to #11A)
11A. IF YOU WISH TO HAVE BENEFITS PAID DIRECTLY TO THE PROVIDER OF SERVICE, PLEASE SIGN BELOW:
AUTHORIZATION TO PAY PROVIDER. For service described, I hereby authorize payment of benefits, if any, to the named provider. I understand I am financially
responsible for the charges not covered by my contract with my insurance company.
PATIENT/SUBSCRIBER’S SIGNATURE: DATE:
12. PATIENT/SUBSCRIBERS’S SIGNATURE
I certify that the information on this claim form is correct and complete, and that I am claiming benefits only for charges actually incurred by the patient named, and hereby
authorize any insurance company, organization, employer or provider of service to release any information with respect to this claim form.
PART II TO BE COMPLETED BY ATTENDING PROVIDER
Any person who knowingly and with intent to defraud, provides any materially false or misleading information, commits a fraudulent act which is a crime.
1. NAME AND LICENSE LEVEL OF REFERRING PHYSICIAN OR OTHER SOURCE (e.g. PUBLIC HEALTH AGENCY) OPTIONAL
2. NAME AND ADDRESS OF FACILITY WHERE SERVICE RENDERED (IF OTHER THAN HOME
3. WAS LABORATORY WORK PERFORMED OUTSIDE
YOUR OFFICE? YES NO
4. DIAGNOSIS OR NATURE OF ILLNESS, RELATE DIAGNOSIS TO PROCEDURE IN COLUMN BY
REFERENCE NUMBERS 1,2,3, ETC., DX CODE OR ICD9:
5. DID THIS CONDITION RESULT FROM PATIENT’S
EMPLOYMENT? YES NO
ACCIDENT? YES NO
WORK AUTO OTHER
DATE OF SERVICE
DESCRIPTION OF PROCEDURE,
SERVICES, AND SUPPLIES
7. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS. I CERTIFY THAT THE
STATEMENTS ABOVE APPLY TO THIS BILL AND ARE MADE A PART THEREOF:
13. PATIENT’S ACCOUNT NO. 11. PROVIDER SOCIAL SECURITY NO./ FED
TAX ID NO. OR PROVIDER EMPLOYER
12. PHYSICIAN’S SUPPLIER’S, AND/OR GROUP NAME,
ADDRESS, ZIP CODE AND TELEPHONE NUMBER
HCFA 1500 REFERENCE MATERIAL
Place of Service Codes (Part II, Field B)
21 Inpatient Hospitalization
22 Outpatient Hospitalization
23 Emergency Room – Hospital
24 Ambulatory Surgical Center
25 Birthing Center/Free Standing
26 Military Treatment Facility
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
41 Ambulance – Land
42 Ambulance – Air or Water
50 Federally Qualified Health Center
51 Inpatient Psychiatric Facility
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Center
54 Intermediate Care Facility/Mental Retardation
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
60 Mass Immunization Center
61 Comprehensive Inpatient Rehabilitation Facility
62 Comprehensive Outpatient Rehabilitation Facility
65 End – Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
83 Correctional Facility
84 Other Community Setting
85 Drop-in Center
86 Foster Home
87 Place of Employment
99 Other Unlisted Facility