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. Payment for requests submitted from the 1st to the 15th of the month will be mailed by the last day of the month. Payment for requests submitted from the 16th to the last day of the month will be mailed by the 10th of the next month. The SMBH Fund is a payor of last resort, please do not submit a request for reimbursement until all insurance claims have been paid. The SMBH Fund will not reimburse any requests for payment for clients who miss their appointments. If you have any questions, please contact Tri-County Health Network at email@example.com.
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.