USP Fall 2018 Mental Health Refund Application
The Undocumented Student Program (USP) at UC Berkeley recognizes that not all all mental health needs can be met on campus and is committed to reducing financial barriers for off-campus mental health support. If you're undocumented and you've attended therapy off-campus (or other mental health related appointment e.g. psychiatrist, medical doctor for depression/anxiety medication, ADHD evaluation, couples counseling, etc.) you can apply for a refund for amount you had to pay out of pocket. For most students this will be your SHIP co-pay. If you don't have access to insurance and need support paying for the entire amount, please contact Diana at the number listed below.

ELIGIBILITY:
In order to qualify for mental health reimbursement funds, students must meet all of the following criteria:
1) Must be a current UCB enrolled student*
2) Must be low-income as defined by financial aid guidelines
3) Must not be eligible for federal financial aid (pell grant, federal loans, etc.)
4) Must use any available health care coverage first, then request refund for outstanding co-pay/fees.

*Note: Current enrollment is required to process refund request, but you are still eligible for refunds for mental health services you accessed during a Leave of Absence (LOA), and/or Summer & Winter breaks. When this is the case, you must request a refund during the first term that you're re-enrolled at UCB. Unfortunately, we cannot accommodate requests for refunds prior to first semester at UCB or post-graduation.

APPLICATION:
Please fill out all required information listed below. In addition, please upload supporting documentation which should have been provided by the mental health provider from which you received services. This could be a receipt showing how much money you paid out-of-pocket, a billing statement, or an invoice that lists the date (s) of service and amount you were responsible to pay that was not covered by insurance. If you've lost these records, you can request a duplicate invoice from the therapist or other mental health provider. Once request is approved, you will receive an email from USP staff informing you that a refund will being sent through your CalCentral account and should be available within the following 7-10 business days. Refunds are processed once a term.

***The Fall 2018 deadline has been extended to Friday, December 7, 2018 by 5pm***

For questions or issues related to documentation, criteria, etc., please call Diana Peña @ (510) 664-7483.

Email address *
Untitled Title
First Name *
Last Name
Student ID # *
Address *
Phone number with active voicemail *
Total amount ($) of refund being requested this term *
Please upload all supporting documentation here. For an example of a mental health invoice (which you can request from your provider), see image below. *
Captionless Image
Required
Additional comments or special circumstances you'd like to us to consider (Optional)
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of UC Berkeley. - Terms of Service