Mental Health Parity Disclosure Request Form

This document is about a form to request information from an employer-sponsored health plan or insurer regarding limitations that may affect access to mental health or substance use disorder benefits. The form helps individuals obtain documentation on treatment limits, financial requirements, and other parity protections under the Mental Health Parity and Addiction Equity Act (MHPAEA). It provides instructions on how to complete the request and the type of information the plan must provide, such as the specific plan language, factors used to develop the limitations, and evidence that the limitations are applied no more stringently to mental health/substance use disorder benefits than medical/surgical benefits.