Insurance Violation Tracking Form

If your doctor refers or prescribes mental or substance use care, including medication and therapy, that your insurance company denies, that denial may be a violation of the Georgia Mental Health Parity Act. This form is designed to help you submit complaints about such potential parity law violations. NAMI GA can assist you in filing your complaint.

Please write down this email (advocacy@namiga.org) and phone number (770-408-0625) in case you have a problem navigating any of these portals or filling out a complaint and we will assist you .We will follow up with you to be sure that you were able to complete the complaint process.

Question Title

* 1. Is it ok for NAMI Georgia to use your information to advocate for equal treatment for mental health?
(We will not share your email or phone number)

Yes

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* 2. Patient's Name

First Initial and Last Name

City/Town

ZIP/Postal Code

Email Address

Phone Number

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* 3. What Kind of Insurance Do You Have?

CareSource (Medicaid)

PeachCare For Kids (Medicaid

AmeriGroup (Medicaid)

Kaiser (Private)

Cigna (Private)

Blue Cross Blue Shield (Private)

Centene (Private)

Aetna (Private)

Cigna (Private)

Humana (Private)

Other (please specify)

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* 4. All of the insurance plans listed above require the insurer to cover behavioral and mental healthcare in the same manner it covers medical/surgical care.

Please check each box below where you believe you have experienced unequal coverage or treatment for behavioral and mental health.

Can’t find a provider: You either had to go out of network to find a provider and/or you had to wait more then two weeks for an appointment.

Medical necessity: Your doctor prescribes a mental health treatment that your insurance company states is not medically necessary.

Higher payments: Your out-of-pocket costs (i.e., co-pays) for mental health services are higher than for your medical/surgical care.

Limitations: You are limited in how many times you can see a mental health care provider, but face no such limits for your physical health care.

Higher costs for medicine: Your co-pays are higher for prescription medications to treat mental health than for physical health.

Needing permission: Your insurance company requires your doctor or mental health care provider to obtain permission prior to accessing mental health treatments, but not physical health treatments.

Forced to take less expensive treatment: Your insurance company requires that you try a less expensive treatment option before covering the treatment your mental health provider prescribes.

Separate deductible: Your insurance plan has a separate deductible for mental health services.

Other (please specify)

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* 5. Please describe your experience trying to get mental health care covered by your insurance.

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* 6. Would you be interested in sharing your story with a reporter?

Yes

Insurance Violation Tracking Form

Question Title

* 1. Is it ok for NAMI Georgia to use your information to advocate for equal treatment for mental health?(We will not share your email or phone number)

Question Title

* 2. Patient's Name

Question Title

* 3. What Kind of Insurance Do You Have?

Question Title

* 4. All of the insurance plans listed above require the insurer to cover behavioral and mental healthcare in the same manner it covers medical/surgical care.Please check each box below where you believe you have experienced unequal coverage or treatment for behavioral and mental health.

Question Title

* 5. Please describe your experience trying to get mental health care covered by your insurance.

Question Title

* 6. Would you be interested in sharing your story with a reporter?

* 1. Is it ok for NAMI Georgia to use your information to advocate for equal treatment for mental health?
(We will not share your email or phone number)

* 4. All of the insurance plans listed above require the insurer to cover behavioral and mental healthcare in the same manner it covers medical/surgical care.

Please check each box below where you believe you have experienced unequal coverage or treatment for behavioral and mental health.