CIH Textbook Reimbursement Form

Community Integrated Health (CIH) Textbook Reimbursement Form
Textbook reimbursement is available for the CIH course for participants in Montana Office of Rural Health/Area Health Education Center (MORH/AHEC) programs. These programs are the Montana Family Support Program and the Behavioral Health Training Program.

Please complete and submit this form to have your expense reimbursed.

Reimbursement can be expected from MORH/AHEC, in the form of a check, to the address provided in 4-6 weeks.
Name:*

First NameLast Name
Organization*
Course Date*

MonthDayYear
Date
Which program are you a participant in?*

Behavioral Health Training ProgramMontana Family Support ProgramScholarship RecipientOther
E-mail Address:*
Address to Mail Check:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Textbook Reimbursement Uploads
If you are a participant in the Behavioral Health Training Program or Montana Family Support Program, or a scholarship recipient, please upload your textbook receipt here.
Upload receipt.*

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Please upload a completed W-9 here. A template may be found at the IRS website: W-9 Fillable Form.
Upload W-9.*

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Signature
I confirm that the information given in this form is true, complete and accurate. *

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