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 CDC COVID-19 Health Equity Grant, 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?*

CDC COVID-19 Health Equity GrantBehavioral Health Training ProgramMontana Family Support ProgramScholarship Recipient
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 CDC COVID-19 Health Equity Grant, Behavioral Health Training Program, 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
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