Long-Term Care COVID-19 Reimbursement Request Form
Submit your reimbursement request for COVID-19-related expenses incurred in a long-term care setting. Please provide accurate and complete information to ensure prompt processing.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Facility or Organization Name
*
Expense Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expense Category
*
Please Select
Personal Protective Equipment (PPE)
Testing Supplies
Staffing Costs
Cleaning & Disinfection
Other
Expense Description
*
Amount Requested (USD)
*
Upload Supporting Documentation
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional Comments (optional)
Submit Request
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