Behavioral Health Fund Reimbursement Request

    Every section of this request must be completed in its entirety. Incomplete requests will not be processed. Only one request per provider per month, please.

    Text explaining the form/process here.

    Provider Information

    Billed Sessions

    Electronic Signature Agreement

    I certify, to the best of my knowledge, that all information in this request is true and accurate. Etc. Etc..

    The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

    (Use your mouse or trackpad to sign.)

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