Family Mental Health Care Fund Provider Attestation Form

The Community Foundation of the Texas Hill Country

Family Mental Health Care Fund Provider Attestation Form
If you are a licensed provider seeking reimbursement through the Family Mental Health Care Fund established by the Community Foundation of the Texas Hill Country to support people who lost family members through the Texas Hill Country floods on July 4, 2025, 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 Provider Entity Seeking Reimbursement
Name of the Individual Providing Care*

First NameLast Name
License Type of the Provider*
License Number*
Licensing State*
If the Provider is part of an organization or legal entity, please provide that Name*
Authorized Signatory Full Legal Name*

First NameLast Name
Authorized Signatory Title*
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
Client Attestation Form

To be completed by the person receiving services from the Provider Entity or their parent / legal guardian if the person is under 18 years of age. Download a copy from the embedded PDF below for the Client to complete and sign.
Upload Completed Client Attestation Form Here*

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Attestation Statement

To be completed by authorized representative of the Provider Entity submitting a request for reimbursement.
*

I affirm that the provider listed as the individual provider provided services to a family member of a person who lost their life in the Texas Hill Country floods on July 4, 2025, or in a flood-related death that occurred after the July 4 floods.I affirm the person listed as the individual provider is currently licensed to provide outpatient mental health services, in good standing, and eligible to practice and bill independently for services.I am requesting reimbursement for expenses for counseling services provided pro bono, free of charge, and / or at a discounted rate between July 4, 2025, and December 31, 2026.I understand that I will be reimbursed according to my established rate sheet for expenses consistent with customary and usual rates in the region in which I provided care.I affirm that, if the client does not have insurance that pays any portion of the costs of the care I have provided, as the Fund requires that clients with insurance use their insurance. If I have billed the client’s insurance and the client needs reimbursement for uncovered costs (i.e., copay, coinsurance, deductible), the client must seek that reimbursement independently.I have fully read the information provided through the Family Mental Health Fund Frequently Asked Questions (FAQs) as well as the Family Mental Health Fund Frequently Asked Questions for Provider Reimbursement and I understand and comply with the purpose and limitations of the Fund.I will not provide any personal information about my Client other than the information that has been expressly requested, and I understand that if any personal information is provided that has not been expressly requested, it will be disregarded and permanently destroyed to protect the privacy of the client.I affirm that all phone numbers, email addresses, and mailing addresses provided are current and in service.I agree to notify the Fund within 15 days if any of the provided information attested to above changes during the eligibility period.I affirm that the information provided in this attestation is complete and accurate to the best of my knowledge and that all listed individuals consent to inclusion for eligibility purposes.
Signature of Applicant*
Date*

MonthDayYear
Date
Should be Empty:

The Community Foundation of the Texas Hill Country

Contact Information for the Provider Entity Seeking Reimbursement

Client Attestation Form

Attestation Statement