MSU Counseling & Mental Health Services

Reimbursement Request

Have questions about which services are covered or how reimbursement is calculated? You may review the MSU Counseling & Mental Health Services Fund website by clicking here or contact JND Legal Administration by email at Info@MSUHealingFund.com or by phone toll-free at 1-877-250-6408.

Instructions for Completing a Reimbursement Request

SECTION 1: PERSONAL INFORMATION

Applicant's Name

Contact Information

Relationship

I received treatment at an MSU health clinic or as an MSU student-athlete.
I am the Spouse, Parent or Legal Guardian during or after the time the patient/survivor received treatment.

Insurance Information

I attest I am uninsured and have not received reimbursement for services during the time in which the eligible services were provided. I acknowledge that the reimbursement for an uninsured eligible recipient is the lesser of reasonable and customary allowance as defined by the fund or actual expenses incurred.

SECTION 2: REIMBURSEMENT REQUEST

Complete this section with assistance from the behavioral health provider:
  • Submit a separate request for each different provider/service
  • Attach an Explanation of Benefits (EOB) or itemized bills
  • Refer to www.MSUHealingFund.com for assistance
  • Failure to submit appropriate documents will delay consideration for reimbursement

Other Services

Attach pharmacy prescription receipts. Visit www.MSUHealingFund.com/services to view eligible prescription medications. Itemized bills from the pharmacy should include patient name, pharmacy name, address & phone number, date(s) of service, medication name & dosage, out-of-pocket expense for each medication.
Attach written recommendation from provider and receipts for eligible expenses. Visit www.MSUHealingFund.com/services for eligibility criteria.

SECTION 3: ATTACHMENTS

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Section 4: Additional Notes

Using the text box below, you have the option to include any additional information that should be taken into consideration while processing your reimbursement request (e.g., new service or provider, insurance notes, specific service dates within documentation that do not need to be processed as part of your current reimbursement request, etc.)

If anything additional is needed to process your request after reviewing your submission and any additional notes, we will reach out via email.

(500 character limit)

SECTION 5: CONFIRMATION

I understand that the Counseling and Mental Health Services Fund ("Fund") is set up to provide financial support to patients, patients' parents or legal guardians, and patients' spouses for certain out-of-pocket expenses, including co-pays, deductibles, or co-insurance, related to eligible mental health services, until the Fund is depleted.

I am requesting reimbursement for out-of-pocket expenses for eligible mental health services. I understand that reimbursement is subject to the eligibility requirements of the Fund.

I understand that the Fund is a payor of last resort. I will not submit any claims for reimbursement unless all other insurance coverage has been exhausted.

By submitting this Reimbursement Request, I agree and certify that I will comply with all applicable federal and state laws and any applicable program policy or procedure of the Fund.

Submission of false claims, statements, documents, or concealment of a material fact may be prosecuted under applicable federal and state laws.

I attest that all information submitted in my Reimbursement Request(s) is accurate and complete.