OMB control number

COVID–19 Provider Relief Programs Application and Attestation Portal, and Claims Reimbursement Submission Activities

OMB 0906-0069 · HHS/HRSA.

OMB 0906-0069

Latest Forms, Documents, and Supporting Material

Document Name
Form 4 Uninsured Provider (UIP) Application Form
Form 3 Coverage Assistance Fund (CAF) Application Form
Form 2 PRF and ARP-R Application Portal Form
Form 1 Provider Relief Fund (PRF) and American Rescue Plan Act Rural (ARP-R) Attestation Portal Form
Supporting Statement A.docx Supporting Statement A
Uninsured Provider (UIP) Application Form
Coverage Assistance Fund (CAF) Application Form
PRF and ARP-R Application Portal Form
Provider Relief Fund (PRF) and American Rescue Plan Act Rural (ARP-R) Attestation Portal Form

All Historical Document Collections

202201-0906-002

2022-01-21