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.




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.


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.