This request form is for Members or Subscribers only. Providers should call 1.800.925.5327 Option 6 for claims information. Patient Name*Subscriber Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address* Phone Number*Patient Date of Birth* Date Format: MM slash DD slash YYYY Subscriber Company Name*Date Beginning* Date Format: MM slash DD slash YYYY Date Ending* Date Format: MM slash DD slash YYYY Additional Comments EOBs will only be provided to an address that matches the subscriber or member's name and/or address or an address that has been previously verified and is on file with American Behavioral. By submitting this request, you agree and attest that you are the covered member or subscriber. EOB requests will be processed within 3 business days of receipt.
