MSU Counseling & Mental Health Services

Provider Reimbursement Request

This form is for providers submitting directly to the MSU Counseling & Mental Health Services Fund for reimbursement of outpatient counseling and/or other outpatient mental health treatment services. A patient must have previously submitted at least one request for reimbursement to the Healing Fund directly, and been reimbursed for that request, before a provider can submit a request for reimbursement on the patient's behalf.

SECTION 1: PROVIDER INFORMATION

Behavioral Health Provider

Email Address *

Phone Number

Address

City

State

Zip Code

Provider Tax ID

Provider NPI

Patient’s Diagnosis

I understand that all available insurance coverage must be exhausted to qualify for reimbursement and that all services requested must be submitted to insurance prior to requesting reimbursement. Reimbursement is limited to out-of-pocket expenses, including deductibles, co-pays, or co-insurance. The Fund is the payor of last resort.

SECTION 2: PATIENT INFORMATION

First Name *

Last Name *

Middle Initial

Date of Birth *

Last Five Digits of SSN *

Current Address

Email Address *

City *

State

Zip Code *

SECTION 3: ATTACHMENTS

Please attach a copy of the Explanation of Payment/Processing (EOP) for all service dates in the request, in addition to any other relevant documentation (e.g. Superbills).

Max file size 2gb, file types PDF, TIF, JPG, JPEG, PNG.

Add File

#	File Name
1

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 of out-of-pocket expenses for eligible, outpatient mental health services on behalf of an eligible patient. 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 for the patient has been exhausted, and that I must provide copies of the EOP for each service being requested.

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

Title

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