Complete the information below for all family members (including yourself) who are age 14 or older. Use + to add people
Insurance Waiver Appeal: You may request that your application for the Mental Health Client
Assistance Program be considered if you feel there are special and unusual circumstances. Special
or unusual circumstances could include mental health services not being a covered service with your
current insurance or the inability to pay large deductibles or copays. The appeal must be in writing
stating the reasons the waiver should be granted and desire for review. The Mental Health
Supervisor, in consultation with the Director, will review requests and determine if waiver will be
granted. If the waiver is granted, the Mental Health Client Assistance Program fee schedule will be
utilized to assess any potential fees.
My signature below authorizes the exchange of information between Southern Minnesota
Behavioral Health and Brown County Human Services to include
All information provided on this application
• Copies of proof of income reported.
• Diagnostic information including mental health professional recommendations
• Service dates and services provided
I understand this information is needed in order to process my application for the Client Assistance
Program and will not be used for any other purpose other than eligibility determination for the Client
Assistance Program. I understand the request for Mental Health Client Assistance Program funding
and I agree with this request for assistance. I understand that the consent will automatically expire
one year from the date of my signature. I understand that I may revoke this consent at any time upon
written notice (not retroactive) and if I revoke my consent to share information with Brown County
Human services my eligibility for the Mental Health Client Assistance Program will also be revoked.
