Behavioral Health Fund Reimbursement Request


    This form is for behavioral health services providers to request reimbursement for services provided to patients covered by the San Miguel Behavioral Health Fund. Tri-County Health Network will process requests and remit payments twice per month. Requests submitted from the 1st to the 15th of the month will be included in the first payment and requests submitted from the 16th to the last day of the month will be included in the second payment. Payment will be mailed within 10 business days of the end of each period. The SMBH Fund is a payor of last resort, please do not submit a request for reimbursement until all insurance claims have been paid. If you have any questions, please contact Tri-County Health Network at

    Provider Information

    Billed Sessions

    Electronic Signature Agreement

    I certify, to the best of my knowledge, that all information in this request is true and accurate. I understand that all billed sessions are subject to verification and approval by Tri-County Health Network.

    The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

    (Use your mouse or trackpad to sign.)

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