Forms to be Returned to the Lung Association

Step 1 - Fill out the purchase log itemize your incentive purchase and attach your receipts to the log. Make a separate entry in the log for each receipt you submit. To receive reimbursement, a purchase log with receipts attached must accompany each reimbursement request. The forms and receipts can be submitted throughout the year; however, they must be received before December 15 of each calendar year.

Step 2 - Fill out the disbursement record each time you provide an incentive to a client. First, record the date the incentive was provided to the client. Then, record the client's initials and the client's date of birth for client tracking purposes (clients need not sign the record themselves). Make one check in either the "Suspect/Active TB Case" or the "Latent TB Infection" column to indicate what type of tuberculosis the client has. Indicate the type and approximate value of the incentive used.

Step 3 - Fill out the reimbursement request at the time you decide to request reimbursement from the American Lung Association of Wisconsin. Indicate to whom or what agency the check should be made payable, to whom the check should be mailed, your agency name, and the correct mailing address. Indicate the total amount you are requesting to be reimbursed (which should match the total amount on the purchase log and be equal to the attached receipts). Sign and date the request.