Oxford School Mental Health Funding Assistance/Co-Pay Reimbursement

Oxford School Mental Health Funding Assistance/Co-Pay Reimbursement

Oakland County’s Board of Commissioners (BOC) is partnering with the Oakland Community Health Network (OCHN) to launch an Oxford School Mental Health Funding Assistance Program in support of persons directly impacted by the Oxford tragedy.

The BOC has committed $500,000 to provide students of Oxford schools and their families, as well as school administrators and staff, with up to $4,000 per household for assistance with insurance co-pay / deductible payments associated with mental health care.

Please find the list of documentation that is required to process any reimbursement request.

Parent/Guardian driver’s license/ID
Proof of Oxford School Connection: Student ID, student’s progress report from school, school staff ID, pay stub
Consent completed and attached (typed signature is not able to be accepted; electronic/wet signature is required)
W9 completed and attached
Receipts from mental health provider starting 12/1/2021, indicating date of services and payment of those services (Explanation of benefits/bank statements are not able to be accepted)

Please note there will be a significant delay in processing your reimbursement if you do not upload all required documents.

If you would like more information on OCHN’s Mental Health School Navigator program, please call 248-462-6294 or email schoolnavigator@oaklandchn.org

Date

First and Last Name*

Requestor*

Select or enter value

Email*

Telephone Number*

Mailing Address*

Did you seek mental health care related to Oxford?*

Select or enter value

Submitted For*

Select or enter value

Insurance Status

Select or enter value

Total Dollar Amount Requested*

Amount Requested Per Person*

Use this space to list the names of the persons included in the total dollar amount requested, as well as the amount associated with their individual mental health services.

Proof of Mental Health Services, Co-Pay / Deductible Payments*

Please use this space to submit your required documentation:

Parent/Guardian driver’s license/ID
Proof of Oxford School Connection: Student ID, student’s progress report from school, school staff ID, pay stub
Consent completed and attached (typed signature is not able to be accepted; electronic/wet signature is required)
W9 completed and attached
Receipts from mental health provider starting 12/1/2021, indicating date of services and payment of those services (Explanation of benefits/bank statements are not able to be accepted)

Please note there will be a significant delay in processing your reimbursement if you do not upload all required documents.

Select this link for fill-in-the-blank service consent form.

*1 consent per student.

Select this link for fill-in-the-blank W-9 form

*Budget & Finance issues 1099's to individuals whose reimbursements total $600 or more for the year if applicable.

Drag and drop files here or

Student Information Only - If Applicable

Please use this space to provide information about your child / student. If this section does not apply to you, insert N / A in the field.

Student 1: Name, Birthdate, Grade, School*

Student 2: Name, Birthdate, Grade, School*

Student 3: Name, Birthdate, Grade, School*

Other Students: Name, Birthdate, Grade, School*

Oxford School Staff Only

Select N/A if this section does not apply to you.

Which option best describes your position?*

Select or enter value

Select the building where you work.*

Select or enter value

OCHN does not share people's information.

Send me a copy of my responses

Privacy Notice|Report Abuse