Grace is at work, even in your hardest moments

Every time you travel for treatment, you must complete a Travel Reimbursement form and submit it, along with the corresponding receipts. If you have any questions, please email us or call Ashley at 334-748-2213.

Travel Reimbursement Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Email

Date of Treatment

MM

DD

YYYY

Type of Treatment

How should we reimburse you? Venmo or PayPal?

NOTE: Please add your Venmo @ Name or PayPal email address.

Please list items of reimbursement with $ amount

(Flight, lodging, Uber/Lyft/taxi, parking fees, meals, gas, rental). Please list amount to be reimbursed. List one item per number. Ex. 1. Flight $543, 2. Lodging $425, 3. Meal $235, etc.

Total $ amount requested.

(Please total all receipts.)

Grace is at work, even in your hardest moments

Travel Reimbursement Form

Thank you for your submission! We will review your request and be in touch shortly. If everything is in order, we will route a payment via the platform you indicated (preferably Venmo or Paypal). If we have any questions, we will reach out.

Questions before getting started? Get in touch.