Family Mental Health Care Fund Family Attestation Form

The Community Foundation of the Texas Hill Country

Family Mental Health Care Fund Attestation Form
If you are a person seeking support through the Family Mental Health Care Fund established by the Community Foundation of the Texas Hill Country, please complete the information below. If you have questions about the Fund, please use this link for answers to Frequently Asked Questions (FAQ).
Contact Information for the Person Seeking Supports
Full Legal Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If the person is under age 18, please provide the name of their parent or legal guardian.

First NameLast Name
Family Information
Full Name of the Family Member Lost in the July 4 Floods

First NameLast Name
Release of Information - Authorization to Disclose Health Information
To ensure individuals requesting reimbursement meet the eligibility requirements of the Fund, confirmation may also be obtained by the Meadows Institute from the Provider Entity to confirm eligibility of the behavioral health services provided. This will include 1) confirmation that behavioral health services were rendered, 2) the date(s) of service provided, and 3) billing information including but not limited to amounts billed, copays/coinsurance collected, and amounts received.

Please download a copy of the following Authorization to Disclose Protected Health Information form to complete, sign, and upload below.
Upload Completed Authorization Form

Cancelof
Attestation Statement

To be completed by the person receiving reimbursement or their parent/legal guardian if the person is under age 18.
Signature of Applicant
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

The Community Foundation of the Texas Hill Country

Contact Information for the Person Seeking Supports

Family Information

Release of Information - Authorization to Disclose Health Information

Attestation Statement