COVID-19 Vaccination Reimbursement Request
Community Vaccination Event Information*
COVID-19 Vaccine Pin Number:
3090
Eligible Vaccinations**: 3090
Please select yes or no to the following questions to determine eligible reimbursement:
Yes Did your organization provide event management, traffic control and logistics for this event?
No Did your organization provide administrative staff for this event?
No Did you organization provide vaccination staff for this event?
Reimbursement Calculator
Rate
Eligible Event
Reimbursement
$10 $30,900
$5 $0
$15 $0
$30,900
Additional Cost Summary***:
Total additional cost:
7164.98
Less other funding/reimbursement:
Net additional cost: $7,165
Total Request Amount:
$38,065
* Community Vaccination Events may span multiple days as long as the event location remains the same. All
dates should be specified.
** If seeking third-party reimbursement for the services at the event was not appropriate or feasible, then all
vaccinations are eligible for reimbursement. If billing third party payers was feasible, then only vaccinations not
eligible for insurance reimbursement are eligible for Staffing Reimbursement.
Item
Event Mgmt, Traffic, Logistics
Administrative Staff
Vaccination Staff
Total Event Reimbursement Amount
600 North Wheeler Avenue
Prosperity
Provider Name:
Lovelace Family Medicine
VFC136100
Location Name:
Lovelace Family Medicine
Location Address (incl zip):
Total # Vaccinations:
Date & Times:
04/01/21-04/30-21 (various times)
Inv. 002
1) Summary Description of Request and Costs
- office supplies such as printer labels and colored paper (to use for patient handouts)
- Signage for office vaccination drivethru
- The vaccine drivethrough
has been and is open
3) Describe activities conducted and outcomes expected or achieved
4) Is the cost being covered by any other funding source or insurance? Please explain.
Insurance reimbursement was received for admin of some vaccines.
5) Were all avenues of funding exhausted before using Vaccine Reserve Account funds? Please explain.
- Costs for creation of website for LFM Vaccine information and registration. Included are fees for
payment of website domain, Happy FORMS for creation of registration and Calendy for availibility
calender linked to registration form
- Creation of onsite office vaccine drivethru including: gravel for new driveway, insulation board and
AC window unit for drivethru "shed" (which staff utilize), electrical costs for wiring of drivethru shed
- 2 portable LIONCooler Fridge/Freezer's with solar panels and one pack of Elitech pen style dada
loggers
2) Describe Benefit to the State of South Carolina and Statewide Vacinnation Efforts including the future
distribution and administering of vaccines.
Our office over the past months focused our efforts as a whole on vaccine distribution to Newberry
County and surrounding counties. Due to this focus we have had decreased revenue in normal office
operations. The office has continued to pay out of pocket for additional staffing for vaccine clinics,
supplies, and efforts (such as advertising) to increase vaccine awareness and therefore utilization.
*** Claiming additional costs requires detailed justification and documentation. Please attach answers to the
following questions:
COVID-19 Vaccination Reimbursement Request
Please select yes or no to the following questions to determine eligible reimbursement:
Did your organization provide event management, traffic control and logistics for this event?
Did your organization provide administrative staff for this event?
$38,065
* Community Vaccination Events may span multiple days as long as the event location remains the same. All
dates should be specified.
** If seeking third-party reimbursement for the services at the event was not appropriate or feasible, then all
vaccinations are eligible for reimbursement. If billing third party payers was feasible, then only vaccinations not
eligible for insurance reimbursement are eligible for Staffing Reimbursement.
600 North Wheeler Avenue
Prosperity
Lovelace Family Medicine
Please fill in the green cells in this
document to calculate the eligible
reimbursement for your event. This form
will need to be submitted in the invoice
portal either as a PDF or XLSX file for each
testing event.
VFC136100
Lovelace Family Medicine
04/01/21-04/30-21 (various times)
- office supplies such as printer labels and colored paper (to use for patient handouts)
3) Describe activities conducted and outcomes expected or achieved
4) Is the cost being covered by any other funding source or insurance? Please explain.
Insurance reimbursement was received for admin of some vaccines.
5) Were all avenues of funding exhausted before using Vaccine Reserve Account funds? Please explain.
- Costs for creation of website for LFM Vaccine information and registration. Included are fees for
payment of website domain, Happy FORMS for creation of registration and Calendy for availibility
calender linked to registration form
- Creation of onsite office vaccine drivethru including: gravel for new driveway, insulation board and
AC window unit for drivethru "shed" (which staff utilize), electrical costs for wiring of drivethru shed
- 2 portable LIONCooler Fridge/Freezer's with solar panels and one pack of Elitech pen style dada
loggers
2) Describe Benefit to the State of South Carolina and Statewide Vacinnation Efforts including the future
distribution and administering of vaccines.
Our office over the past months focused our efforts as a whole on vaccine distribution to Newberry
County and surrounding counties. Due to this focus we have had decreased revenue in normal office
operations. The office has continued to pay out of pocket for additional staffing for vaccine clinics,
supplies, and efforts (such as advertising) to increase vaccine awareness and therefore utilization.
*** Claiming additional costs requires detailed justification and documentation. Please attach answers to the
following questions:
Additional Cost Summary April 2021
1- Summary Description of request and costs.
a. Costs for creation of website for LFM Vaccine information and registration. Included
are fee payment of website domain, Happy FORMS for creation of registration and
Calendy for availability calendar linked to registration form.
b. Office supplies such as printer labels and colored paper (to use for patient handouts)
c. 2 portable LIONCooler Fridge/Freezer’s with solar panels ad one pack of Elitech pen
style data loggers
d. Signage for office vaccination drivethru
e. Creation of onsite office vaccine drivethru including: gravel for new driveway,
insulation board and AC window unit for drivethru “shed” 9which staff utilize,
electrical costs for wiring of drivethru shed.
2- Describe benefit to the state of South Carolina and statewide vaccination efforts including the
future distribution administering of vaccines.
a. The vaccine drivethru has been and is currently open and continues to see regular
traffic throughout M-F and 9-11 am on Saturdays.
b. Increased accessibility to offsite locations for vaccine clinics particularly in rural areas
that have had limited access.
3- Describe activities conducted and outcomes expected or achieved.
a. The goal of all efforts including are to work to increase vaccination rates by increasing
opportunity and accessibility, increasing community involvement through
volunteerism, increasing educational opportunities for those who are hesitant about
receiving the vaccine, and dispelling myths associated with receiving the vaccine. We
have worked to increase rates in ours and surrounding counties (which some of have
had lower than state average rates).
4- Is the cost being covered by any other funding source or insurance? Please explain.
a. In some instances administration fees are being billed to the patient’s insurance plan.
5- Were all avenues of funding exhausted before using Vaccine Reserve Account funds? Please
explain.
a. Our office over the past months focused our efforts as a whole on vaccine distribution
to Newberry and surrounding counties. Due to this focus we have had decreased
revenue in normal office operations. The office has continued to pay out of pocket for
additional staffing for vaccine clinics, supplies and efforts (such as advertising) to
increase vaccine awareness and therefore utilization.
LFM April 002
Secure Document Upload
Please upload the invoice PDF to our secure website using the buons below.
Please Upload Invoice for Payment Review
Haley Davis, RN
Contact (Full Name)
784
Tracking Number
(864) 617-0893
Phone EXT
Contact EMAIL
Providers VAX Secure Invoice
Upload
7/21/2021
Date
Contract Informaon
Haley Davis, RN
7/21/2021 6:21:20 PM
Signature (required) Click to Sign
Samuels, Tierra B.
7/28/2021 10:16:03 AM
Budget and Finance Approval
CEO, President
Title
INVOICE NUMBER
INVOICE AMOUNT
The attached invoice is acurate and the invoice total is correct.
Yes
No
$38,065.00
Invoice Total
57-0989480
* Tax ID
7000029556
* SCEIS Number
600 North Wheeler Avenue
* Address * STE #
Prosperity
* City
SC
* State
29127
* Zip
Lovelace Family Medicine, PA
* Contractor Name
Please enter the conract number first to automatically populate the fields listed with an asterisk (*) Please note that these
fields are "Read Only" and edits are not permitted on the form.
To ensure prompt processing of your invoice ensure that you include the invoice number in the file name that you upload.
Please ensure that all required information is included on the invoice. Click below for more details
Bonner, Melissa
7/28/2021 9:51:33 AM
ACC Testing Approval
I certify that no other funds have been
received or will be reimbursed by any
other source for the amounts claimed on
this invoice
Approved Invoices to Date
Approved Funding
$0.00
Availible Funding
002
38,065.00
Full Amount $38,065.00 31070000 Not Relevant J0402AZ998
J040X01058580130 5021310000 98000018
Payment Processing Instructions
Robinson, Sharon D.
7/28/2021 11:19:08 AM
Accounts Payable Approval
OTH-VAX-385
Contract Number (required)
If rejecting this form for any reason please provide a brief note to the agency. It will be included in the rejection email notification
