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Welcome to the ACH Patient Engagement Reimbursement Form. If you have any questions please contact Kelsey Kirsch

Your Name(Required)
Who should the payment be made out to?
What was the purpose of this trip or the reason for this reimbursement. IE did you travel to the spring conference, fall board meeting, e.g.
You can enter up to 20 expenses on one form.

If entering an expense as other you must enter your reason in the notes field near the bottom of the form.

Date should be entered as month/day/year - example - 07/10/2023
Expense Type
Use The + Symbol to add more than one entry.
Mileage Tracker
Mileage (Only enter miles if not inputting gas receipts and/or rental fees).

You can enter up to 10 mileage entries below. More if you use Trip Count.

Please only use whole numbers for number of miles. Round Up to the next whole number (45.5 miles becomes 46 miles)

Route Name This is just a name for the trip. Say you drove from your house to the hotel. You would put something like Home to Hotel or Home to Conference in the route name.

Trip Count: Say you took the same route with the same mileage 5 times. Rather than enter that info 5 times, trip count allows you to enter that trip once then we multiply the miles by the trip count to get your total miles.
Route Name
Trip Count
Total Miles
Use The + Symbol to add more than one entry.
Please upload support for each expense (including route map for mileage). Please submit all receipts in one file when possible. If missing a receipt please let us know in the notes field below.
Drop files here or
Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 8 MB, Max. files: 10.