I understand that the Counseling and Mental Health Services Fund (“Fund”) is set up to provide financial support to patients, patient’s parents or legal guardians, and a patient’s spouse 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, procedure of the Fund.
Submission of false claims, statements, or 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.