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

I have received payment for a Reimbursement Request from JND Legal Administration within the last year and certify that my contact information, insurance information and status have not changed.

Applicant's Name

First Name *

Last Name *

Middle Initial

Date of Birth *

Last Five Digits of SSN *

Contact Information

Address *

Email Address *

City *

State

Zip Code *

Relationship

PATIENT/SURVIVOR

I received treatment at an MSU health clinic or as an MSU student-athlete.

SPOUSE/PARENT/LEGAL GUARDIAN

I am the Spouse, Parent or Legal Guardian during or after the time the patient/survivor received treatment.

Insurance Information

I HAVE INSURANCE I AM NOT INSURED

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.

I have filed a Reimbursement Request with JND Legal Administration within the last year including my insurance information, and the information has not changed. I understand that I must include an Explanation of Benefits (EOB) from all insurance carriers that covered these services, for each request submitted.

Policy Holder Name

Group #

Insurance Company

State

Submit an Explanation of Benefits (EOB) from all insurance carriers that covered these services.

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

NONE

OUTPATIENT COUNSELING/THERAPY

INPATIENT HOSPITALIZATION

RESIDENTIAL TREATMENT

Behavioral Health Provider

Address

Phone Number

City

State

Zip Code

Provider Tax ID

Provider NPI

Patient’s Diagnosis

Who should receive payment for inpatient, residential or outpatient counseling?

(Patient/survivor will be reimbursed if this section is not completed)

PATIENT

PROVIDER

Other Services

PHARMACY

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.

SERVICE OR SUPPORT ANIMAL

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: 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.

Signature

Today's Date

By clicking submit, you attest that all information submitted in your Reimbursement Request(s) is accurate and complete.

Visit this website often to get the most up-to-date information.

Survivors

1-877-250-6408

Providers

1-877-324-2347

Survivors

info@msuhealingfund.com

Providers

ProviderServices@msuhealingfund.com