Grace is at work, even in your hardest moments
Travel Reimbursement Form
If this is your first time to request a reimbursement, you must fill out the Grant Application first.
NOTE: 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.
HOW TO REQUEST REIMBURSEMENT:
INITIAL REQUEST: If this is your first time to request reimbursement, please review the complete Reimbursement Policy. Then click here to fill out the Grant Application. You only need to do this once.
RECEIPTS: Snap a picture or scan your itemized receipts.
NOTE: As of May 6, we are no longer reimbursing for food, but you will need receipts for all other reimbursement items. Upload these in the form.TREATMENT PLAN: Download your After Visit Summary from MyChart or take a picture of documents provided but your doctor. This must include your name and treatment date.
DATES: you will need dates of your travel. Travel reimbursement requests must be submitted within 30 days of the travel date. Expenses incurred more than 30 days prior to the date of submission are not eligible for reimbursement.
PAYMENT TYPE: We will need your Venmo handle or PayPal email address.
Click below to access our secure JotForm.