Provider Reimbursement Form - Family Mental Health Care Fund

The Community Foundation of the Texas Hill Country

Family Mental Health Care Fund Provider Reimbursement Request form
If you are a provider entity seeking reimbursement through the Family Mental Health Care Fund established by the Community Foundation of the Texas Hill Country to support individuals impacted by the Texas Hill Country floods on July 4, 2025, please first use this link to complete Provider Attestation Form. If you have questions about the Fund or submitting your request for reimbursement, please use this link for answers to Frequently Asked Questions (FAQ).
Contact Information for the Provider Entity Seeking Reimbursement
Individual Provider Full Legal Name*

First NameLast Name
Provider Entity Name*
Authorized Signatory 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
Information for the Person Who Received Services
Full Legal Name*

First NameLast Name
If the person is under age 18, please provide the name of their parent or legal guardian.

First NameLast Name
Reimbursement Request
Total Reimbursement Amount Being Requested*
Rate Sheet

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Copy of clinical licensure*

Cancelof
Bill for services provided including the name of the patient and the name of the deceased*

Cancelof
Consent from patient to apply for reimbursement (Client Attestation Form)

Cancelof
Should be Empty:

The Community Foundation of the Texas Hill Country

Contact Information for the Provider Entity Seeking Reimbursement

Information for the Person Who Received Services

Reimbursement Request