COVID-19 Telehealth Request for Reimbursement Form

COVID-19 TELEHEALTH PROGRAM Request for Reimbursement Form
Applicant Information
[All fields mandatory unless otherwise noted]

OMB 3060-1271
2-19-2021

Applicant Name
Funding Commitment Number
FCC Registration Number(FRN)
Applicant National Provider
Identifier (NPI) (Optional)

Contact information [All fields mandatory]
Contact First Name
Contact Last Name
Company Name

Position Title
Mailing Address
City
State
Zip Code
Telephone Number
E-mail
1

OMB 3060-1271

Expense Information: [all fields mandatory]
Recipient
Health
Care
Provider
Name

Recipient
Health
Care
Provider
No.

Service
Location
(Address)
or
Delivery
Location
(Address)

Description of
Service/
Connected
Device(s)
Purchased

Delivery
Date

Quantity of
Connected
Device(s)/
Service(s)

Per Unit
Cost of the
Connected
Device(s)/
Service(s)

Service
Provider/
Vendor
Name

Billing
Period
Start
Date

Billing
Period
End Date

Service
Period for
Recurring
Services

Total Cost

$ 0.00

$ 0.00

$ 0.00

2

OMB 3060-1271

Recipient
Health
Care
Provider
Name

Recipient
Health
Care
Provider
No.

Service
Location
(Address)
or
Delivery
Location
(Address)

Description of
Service/
Connected
Device(s)
Purchased

Delivery
Date

Quantity of
Connected
Device(s)/
Service(s)

Per Unit
Cost of the
Connected
Device(s)/
Service(s)

Service
Provider/
Vendor
Name

Billing
Period
Start
Date

Billing
Period
End Date

Service
Period for
Recurring
Services

Total Cost

$ 0.00

$ 0.00

$ 0.00

3

OMB 3060-1271

Recipient
Health
Care
Provider
Name

Recipient
Health
Care
Provider
No.

Service
Location
(Address)
or
Delivery
Location
(Address)

Description of
Service/
Connected
Device(s)
Purchased

Delivery
Date

Quantity of
Connected
Device(s)/
Service(s)

Per Unit
Cost of the
Connected
Device(s)/
Service(s)

Service
Provider/
Vendor
Name

Billing
Period
Start
Date

Billing
Period
End Date

Service
Period for
Recurring
Services

Total Cost

$ 0.00

$ 0.00

$ 0.00

4

OMB 3060-1271

Recipient
Health
Care
Provider
Name

Recipient
Health
Care
Provider
No.

Service
Location
(Address)
or
Delivery
Location
(Address)

Description of
Service/
Connected
Device(s)
Purchased

Delivery
Date

Quantity of
Connected
Device(s)/
Service(s)

Per Unit
Cost of the
Connected
Device(s)/
Service(s)

Service
Provider/
Vendor
Name

Billing
Period
Start
Date

Billing
Period
End Date

Service
Period for
Recurring
Services

Total Cost

$ 0.00

$ 0.00

$ 0.00

5

OMB 3060-1271

Recipient
Health
Care
Provider
Name

Recipient
Health
Care
Provider
No.

Service
Location
(Address)
or
Delivery
Location
(Address)

Description of
Service/
Connected
Device(s)
Purchased

Delivery
Date

Quantity of
Connected
Device(s)/
Service(s)

Per Unit
Cost of the
Connected
Device(s)/
Service(s)

Service
Provider/
Vendor
Name

Billing
Period
Start
Date

Billing
Period
End Date

Service
Period for
Recurring
Services

Total Cost

$ 0.00

$ 0.00

$ 0.00

TOTAL
AMOUNT

$ 0.00

6

OMD 3060-1271

Certifications [Authorized Person must check all boxes and sign]
I certify under penalty of perjury that the health care provider(s) listed in this request have received the COVID-19 Telehealth Programsupported services and devices listed herein.
I certify under penalty of perjury that I am authorized to submit this request on behalf of the eligible health care provider(s) listed in this form.
I certify under penalty of perjury that I have read the instructions relating to reimbursements and that the above costs were incurred and paid for in
accordance with COVID-19 Telehealth Program rules and procedures, and I have attached the relevant supporting documents
I certify under penalty of perjury that I have examined this form and attachments and, to the best of my knowledge, information, and belief, all
information contained therein is true and correct.
I acknowledge and certify under penalty of perjury that COVID-19 Telehealth Program funds are to be used for their intended purpose.
I acknowledge and certify under penalty of perjury that all documentation associated with this form, including all billing records for
services and/or connected devices received, must be retained for a period of at least three years after the last date of delivery of the
supported-services and/or connected devices provided through the COVID-19 Telehealth Program to demonstrate compliance with
COVID-19 Telehealth Program rules and requirements, subject to audit.
I certify under penalty of perjury that the health care provider(s) listed in this form, to the best of my knowledge, is not already receiving or
expecting to receive other funding (from any source, private, state, or federal) for the exact same services or devices eligible for support
under the COVID-19 Telehealth Program.

Date

Authorized Person Name
Position Title/Company

Digital Signature:

Mailing Address
City
State

---------------------------------

Zip Code
Telephone
Email Address

7

OMB 3060-1271

FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT
Part 54 of the Federal Communications Commission’s (FCC) rules authorize the FCC to collect the information in this form. Responses to
the questions herein are required to obtain the benefits sought by this form. Failure to provide all requested information will delay the
processing of the form. Information requested by this form will be available for public inspection. The information provided will be used to
determine whether approving the request is in the public interest.
We have estimated that your response to this collection of information will take 1 hour. Our estimate includes the time to read the
instructions, look through existing records, gather and maintain the required data, and complete and review the form or response. If you
have any comments on this estimate, or on how we can improve the collection and reduce the burden it causes you, please write the Federal
Communications Commission, Office of Managing Director, AMD PERM, Paperwork Reduction Act Project (3060-1271), Washington, DC
20554. We will also accept your comments via the Internet if you send them to [email protected]. Please DO NOT SEND COMPLETED
FORMS TO THIS ADDRESS.
Remember – you are not required to respond to a collection of information sponsored by the Federal government, and the government may
not conduct or sponsor this collection, unless it displays a currently valid OMB control number or we fail to provide you with this notice. This
collection has been assigned an OMB control number of 3060-1271.
THIS NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION
3507.

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