Business or other for-profit

OMB 3060-1271
2-19-2021
COVID-19 TELEHEALTH PROGRAM REQUEST FOR REIMBURSEMENT FORM

Purpose of the Form

INSTRUCTIONS

This Request for Reimbursement Form serves as the request to the Commission for disbursement of
funding under the COVID-19 Telehealth Program for the eligible services and/or connected devices set
forth by an applicant that received a funding commitment notification (funding recipient). Service
providers or vendors will bill eligible health care providers directly for services and/or connected devices
that they have provided participating eligible health care providers under the COVID-19 Telehealth
Program. Under the COVID-19 Telehealth Program, disbursements will be issued directly to
participating health care providers rather than to the service providers or vendors that have provided
the eligible services and/or connected devices to participating health care providers. Any funding
received by an applicant on behalf of eligible health care provider(s) shall be provided to such health
care provider(s) to reimburse them for their respective costs incurred under the COVID-19 Telehealth
Program.
Following the eligible health care provider’s receipt of eligible services and/or connected devices, and
payment for the services and/or devices provided, in order to receive a reimbursement, funding
recipients must on at least a monthly basis:
(1) Invoice the Commission for services and/or connected devices eligible for COVID-19
Telehealth Program funding through the U.S. Department of the Treasury’s Bureau of the Fiscal
Service Invoice Processing Platform (IPP); and
(2) Upload the following documents as “Attachments” to their invoice submission in the IPP:
(a) at a minimum, an invoice from its service provider or vendor showing receipt of the
service and/or connected devices identifying the eligible services and/or connected devices
purchased and received, and price paid (Note: a purchase order, vendor quote, or other
similar documentation does not demonstrate payment for the services and/or connected
devices);
(b) a Request for Reimbursement Form;
(c) if applicable, a Letter of Authorization for those applicants that received a funding
commitment on behalf of other eligible health care provider sites; and
(d) any additional documentation supporting reimbursement for the eligible cost of the
services and/or connected devices.
If you received and paid for non-recurring services, you can invoice for those services in one
monthly invoice. The Request for Reimbursement Form can be found at
https://www.fcc.gov/sites/default/files/covid-19-telehealth-request-for-reimbursementform.pdf and a sample Letter of Authorization at https://usfcc.app.box.com/v/LetterOfAuthorization.
All of these steps must be completed in order for eligible health care providers to receive
reimbursement for expenses incurred under the COVID-19 Telehealth Program.

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For more information regarding the COVID-19 Telehealth Program invoicing process and how to submit
an invoice and the Request for Reimbursement Form (including supporting documentation) through the
IPP, please see the Commission’s webpage at https://www.fcc.gov/covid-19-telehealth-program and the
Wireline Competition Bureau’s and the Office of Managing Director’s Public Notice (DA 20-425) released
on April 17, 2020.
Filing Instructions
All funding recipients, those filing on behalf of other health care provider sites, and those filing
individually, must use the Request for Reimbursement Form to seek reimbursement where eligible
health care providers have incurred costs for services and/or connected devices eligible under the
COVID-19 Telehealth Program. For individual funding commitments, the “funding recipient” is also the
eligible health care provider. The Request for Reimbursement Form and Instructions can be accessed on
the Commission’s COVID-19 Telehealth Program webpage at https://www.fcc.gov/covid-19-telehealthprogram.
Funding disbursements under the COVID-19 Telehealth Program will ultimately be made to the entity
listed on the funding commitment notification. All applicants that have received funding commitment
notifications under the COVID-19 Telehealth Program must therefore refer to their “Funding
Commitment Number” on their funding commitment notifications during the invoice process.
Payment is made directly to the funding recipient for which the funding commitment was issued. For
applicants that received funding on behalf of eligible health care provider(s), any reimbursements shall
be provided to such health care provider(s) to reimburse them for their respective costs incurred under
the COVID-19 Telehealth Program.
Be sure to complete the form in its entirety. All funding recipients must provide the required
documentation, make the required certifications, and submit a complete COVID-19 Telehealth Program
Request for Reimbursement Form by uploading these documents as “Attachments” to the invoices in
the IPP. The attachments are required for the Commission to process the invoice(s). If you do not
provide the information requested on this form, provide the required supporting documentation, and
submit the invoice(s) through the IPP, the Commission may delay processing the invoice(s). The
Commission’s hand-delivery filing location is closed and cannot be used to submit Request for
Reimbursement Forms for the COVID-19 Telehealth Program.
Supporting Documentation
All supporting documentation must be submitted as “Attachments” to the invoice submission in the IPP.
Please be advised that the IPP will not allow more than 10 MB in size per document and 25 attachments.
Invoices - All funding recipients must submit, at a minimum, an invoice that identifies the eligible
services and/or connected devices purchased and received, and price paid for the services and/or
connected devices. A purchase order, vendor quote, or other similar documentation does not
demonstrate payment for the services and/or connected devices. If you received and paid for nonrecurring services, you can invoice for those services in one monthly invoice. If an invoice from the
service provider or vendor includes ineligible items, be sure to clearly indicate in your invoice submission
the items on the invoice that are eligible (e.g., by crossing out the ineligible items on the invoice). On

OMB 3060-1271
the Request for Reimbursement Form, use the column “Description of Service/Device(s) Purchased” and
indicate where on the invoice the reviewer can find the relevant information for that line item.
Letter(s) of Authorization – For applicants receiving funding on behalf of eligible health care provider
sites, funding recipients must include authorization documentation (e.g., letter) from each participating
eligible health care provider that authorizes the funding recipient to receive funding on their behalf and
provide such funding to the eligible health care providers to reimburse them for their respective costs
incurred under the COVID-19 Telehealth Program. Please see the sample Letter of Authorization on the
Commission’s webpage at https://us-fcc.app.box.com/v/LetterOfAuthorization. Due to the size
limitations of the IPP, attach one pdf with the letters scanned, especially if there are going to be a
number of letters. As indicated above, the IPP will not allow more than 10 MB in size per document and
25 attachments.
Other Supporting Documentation - Funding recipients may also submit any other supporting documents
to support their Request for Reimbursement Form.
Certifications
An authorized person, generally the primary contact for the application, is required to provide all
required certifications and signatures on this form on behalf of the health care provider(s) included in
this application prior to submitting the form. These include, but are not limited to, an
acknowledgement and certification under penalty of perjury that the documentation associated with
this form must be retained for a period of at least three years and are subject to audit. All certifications
must be made to ensure that COVID-19 Telehealth Program funds are being used for their intended
purpose.
Additional Information
For more information about the COVID-19 Telehealth Program, refer to the Commission’s website at
https://www.fcc.gov/covid-19-telehealth-program. Questions specific to your Request for
Reimbursement Form and submission of invoices should be directed to [email protected].

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 this 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.