IMW MHAP Patient Responsibilities
At Insight Mental Wellness, we are committed to supporting our community by offering access to behavioral and mental health services through programs like our Mental Health Access Program (MHAP) and other financial support options. Your eligibility is determined based on several factors including your household income, place of residence within Texas, and any other health coverage you may have. We want to make it clear: your race, ethnicity, gender identity, sexual orientation, religion, political beliefs, disability status, or national origin will never impact your ability to qualify.
By signing below, I affirm that all the information I provide on this application—including income, address, and insurance details—is honest and accurate to the best of my knowledge. I understand that Insight Mental Wellness relies on this information to determine eligibility, and knowingly providing false or incomplete information—or refusing to provide necessary documents—may result in losing access to financial assistance or being asked to reimburse services already received.
I agree to notify Insight Mental Wellness within 14 days if any of the following life changes occur:
– A change in my mailing address or phone number
– A change in where I live
– A change in my or my household’s income
– A change in the number of people living in my home (including pregnancy)
– Enrollment in or approval for Medicaid, CHIP, Medicare, or any other health insurance plan
If Insight Mental Wellness identifies unreported changes that could affect my eligibility, I understand that my enrollment may be placed on hold or ended, and additional steps may be taken, including legal actions when appropriate.
I understand that in order to participate in any financial assistance program, I must allow Insight Mental Wellness to verify the information provided. This verification may involve confirming details with agencies such as the Texas Workforce Commission, Social Security Administration, or Texas Health and Human Services. Until that process is complete, my application may remain under review. Additionally, I understand that if I later receive a settlement or reimbursement related to the care provided (e.g., from a legal claim), Insight Mental Wellness may request recovery of costs.
Use of Eligibility Information
If I am not eligible for MHAP or Insight’s internal financial assistance program, but I am currently enrolled in another provider’s discounted or sliding fee scale program, I authorize the sharing of my application documents with Insight Mental Wellness so they can evaluate if I qualify for assistance through their services.
Consent to Communication
If I have chosen to receive messages by text or email, I understand that Insight Mental Wellness may contact me about appointments, my application status, renewals, and updates to my coverage or eligibility. I acknowledge that such communication may not be encrypted, and others who have access to my phone or email may see the messages. I can withdraw this consent in writing at any time.
Authorization for Third-Party Verification
By signing below, I authorize Insight Mental Wellness to obtain relevant information from my employer and the following state and federal agencies:
– Social Security Administration
– Texas Health & Human Services Commission
– Texas Department of State Health Services
– Texas Workforce Commission
This authorization is valid for up to 12 months from the date of my signature or until I provide a written request to revoke it.