Please complete this form to request reimbursement of expenses.

**PLEASE NOTE - If you have more than 10 line items of expenses, please group your expenses by day. For example, all expenses for Day 1 should be added together and put in the Expense #1 field.

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* Name of Person Requesting Reimbursement

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* Make Check Payable to: (Individual or Institution Name)

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* Phone Number

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* Mailing Address - of the person/entity receiving payment

APTA Home Health Reimbursement Policy

Please click the link above to read the reimbursement policy and then check the box below.

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* I attest that I have read the above linked Reimbursement Policy:

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