Mental Health and Substance Use Disorder Parity Disclosure Request

This document is about a form that can be used to request information from an employer-sponsored health plan or insurer about treatment limitations related to mental health and substance use disorder benefits. It provides background on the Mental Health Parity and Addiction Equity Act (MHPAEA) and instructions on how to complete the form to request general information or specific information about a denied claim. The form allows the user to specify the type of treatment limitations they want information about, and it outlines the plan's obligations to provide the requested information within 30 calendar days.