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Arizona Coalition for Insurance Parity 

Mental Health Parity Story Collection Form

Have you or someone you know been denied coverage for mental health or substance use disorder treatment in the state of Arizona? If so, the Arizona Coalition for Insurance Parity wants to hear from you.  

The Arizona Coalition for Insurance Parity is collaboration between the Arizona Council of Human Service Providers, JEM Foundation, Mental Health America of Arizona, and the Neighbors Council.  We are working to ensure that Arizonans are able to easily access appropriate and timely mental health and substance use disorder treatment through their medical insurance.  

Please fill out this survey if you, or someone you know, has been unable to access needed behavioral health services or  had a claim denied for mental health and/or substance use disorder treatment.  The information you provide will help us to shape public policy and influence legislation in order to move us towards full parity implementation and mental health equity. 

By completing this survey you are acknowledging that your information is being collected to help understand the current trends and circumstances surrounding mental health and substance use disorder treatment claim denials in Arizona.  All information you provide will be kept confidential, and any identifiable information you choose to provide will not be shared without your permission. 
1.The story you are sharing may be about yourself or may be about someone you know well. If you are sharing a story on behalf of someone else, are you:(Required.)
2.If you are sharing a story on behalf of someone else, please respond to the questions below from the perspective of the individual impacted. 

Are you (Check all that apply):(Required.)
3.Age: (Required.)
4.Gender:(Required.)
5.What county do you live in? (Required.)
6.What is your home zip code?(Required.)
7.What issues were you having that caused you to seek mental health or substance use disorder treatment? (Check all that apply):(Required.)
8.What help were you hoping to receive? (Check all that apply)(Required.)
9.What is the name of your insurance company?(Required.)
10.What type of insurance plan do you have? (HMO, PPO, High Deductible Plan, or other?)(Required.)
11.Have you received any of the care you were seeking or requesting?(Required.)
12.If you answered "no" or "some", what services didn’t you receive? (Check all that apply)(Required.)
13.If you answered "no" or "some", why haven’t you received the full care you were seeking? (Check all that apply)(Required.)
14.If your insurer denied your claim or request for services or did not pay for it, what was the explanation? (Check all that apply)(Required.)
15.If you were denied care, have you filed an appeal or complaint with your insurance company?(Required.)
16.If you were denied care, have you filed a complaint with the Arizona Department of Insurance?(Required.)
17.Would you be interested in publically sharing your story to help improve mental health and substance use insurance coverage? This means that someone from the Arizona Coalition for Insurance Parity might be contacting you.(Required.)
18.If yes, please provide your name, phone number, and/or email address so we can contact you.
19.In your own words, tell us about your experience. Please do not include identifiable information, such as names, addresses, social security numbers, etc.(Required.)
20.To file a complaint with the Department of Insurance, please visit their website: https://insurance.az.gov/consumers.   

If you would like more information on insurance parity and your rights, please visit www.DontDenyMe.org.

If you have questions about this survey or mental health parity, please contact Amy Meyertholen, Arizona Council of Human Service Providers, amy@azcouncil.com or fax 602.252.8664.

Thank you for helping us to gather information about access to mental health and substance use disorder treatment.
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