NMDN Reimbursement Request Form

NMDN Reimbursement Request Form

Complete this form to request reimbursement for eligible services provided. Requests must be submitted within 60 days of service delivery.
General Information:
- You can be reimbursed for up to 15 hours per client each calendar year.
- Each provider can receive reimbursement for up to 30 hours per calendar year.
- Reimbursement rate is $50/hour.
- Only one client can be included per Reimbursement Request Form.
- Please allow up to 30 days for the NMDN Reimbursement Committee to review your Reimbursement Request Form and make a final decision.
- All reimbursement is subject to funds availability on a first-come, first-served based on receipt date of completed Reimbursement Request Form.
Required for Reimbursement:

Signed Client Verification Form must be completed electronically OR printed, signed and uploaded with each application for reimbursement.
Section 1: Applicant/Provider Information

All fields are required unless otherwise noted.
Full Name

First NameLast Name
Preferred Name (If different)

First NameLast Name
Preferred Pronouns
Organization or Affiliation
If Applicable
Phone Number
Please enter a valid phone number.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you currently an NMDN Member?

YesNot yet; how do I sign up?No; I'm not interested in membership at this time.
Section 2: Service Details
Dates of Service
Please list dates and hours of service for which you are seeking reimbursement.
Description of Services Provided:
Please be as detailed as possible, while respecting the privacy of your client.
Section 3: Client Verification Form
Client Verification Form can either be completed HERE electronically

OR

you can print the form, fill it out and sign manually, then scan and upload below.
PRINT and upload below.
If filled out manually, please Upload Signed Client Verification Form

Verification of services provided may be signed by the client, family, POA, NOK, etc.
Cancelof
Section 4: Invoice Information

Please upload your invoice.
File Upload

Cancelof
Number of Hours of Service Provided
Reimbursement provided for up to 15 hours per client at a rate of $50/hour.
Total $ Reimbursement Amount Requested
$ US Dollars
Section 5: Certification

I certify that the above services were provided to this client and they are valid business services. I understand that reimbursement is subject to review and fund availability. Please check with NMDN prior to provided pro bono services for which you plan to seek reimbursement.
Signature

Powered by Jotform SignClear
Disclaimer:

NMDN provides limited reimbursement for qualifying services but does not supervise, direct, or endorse any providers. All practitioners are independent and solely responsible for the services they provide.

Dispute Resolution Policy for NMDN Reimbursement Program

This policy outlines the process for resolving disputes related to reimbursement decisions, eligibility determination, or interpretations of policies within the New Mexico Deathcare Network (NMDN) Reimbursement Program. The goal to promote a fair, transparent, and respectful resolution process.

1.    Internal Review:

Providers must submit a written request for reconsideration to the NMDN Board within 15 (fifteen) business days of receiving a notice of a disputed decision. The Board will review the request and issue a written response within 30 (thirty) days.

2.    Mediation:

If the dispute is not resolved through internal review, both parties agree to participate in good-faith mediation. Mediation will be conducted by a mutually agreed-upon neutral third party located in New Mexico. Each party is responsible for their own costs associated with mediation.

3.   Arbitration:

If mediation does not result in a resolution, the parties may proceed to binding arbitration. Arbitration will be administered by the American Arbitration Association (AAA) or another mutually agreed upon provider. The arbitration will be held in Albuquerque, NM, and any judgment may be entered in a court of competent jurisdiction. The decision of the arbitrator will be final and binding.

4.    Waiver of Litigation:

By participating in the NMDN Reimbursement Program, providers agree to waive the right to pursue litigation in court, except for enforcing an arbitration award.
Signature

Powered by Jotform SignClear
Should be Empty:

NMDN Reimbursement Request Form

Section 1: Applicant/Provider Information

Section 2: Service Details

Section 3: Client Verification Form

Section 4: Invoice Information

Section 5: Certification