Long Term Care Covid-19 Testing Reimbursement
Michigan Department of Health and Human Services
Input information about your nursing home in the table below.
Long Term Care Information
Facility Name	Facility License Number
Facility NPI (If a Nursing Home)	Facility SIGMA Vendor ID	Facility SIGMA Address Code
Facility Address
Facility Contact	Contact’s Email
Facility Type
Adult Foster Care Facility	Home for the Aged	Nursing Home
Contact’s Phone Number	Reimbursement Period
Input reimbursable testing expense information below, the information reported must be consistent with all COVID-19 testing reimbursement guidance issued by the Michigan Department of Health and Human Services and may be subject to audit. Click the tab key after entering each amount to update totals listed below.
Testing Related Reimbursement Information
CLIA Waiver Expense (AFCs and HFAs only)	$
Lab Related Expenses (Confirmatory tests only)	$
Number of Tests Processed
Number of Tests Collected by the Long Term Care Facility

The table below shows the total reimbursement for lab related expenses due to Long Term Care Facility
Testing Reimbursement Due
CLIA Waiver Reimbursement	$	0.00
Lab Related Reimbursement (Lab Name)	$	0.00
Specimen Collection Reimbursement	$	0.00
Total Reimbursement	$	0.00
By signing the individual’s name below (physical signature is not required) and checking the certification box, the individual or officer signing this Long Term Care COVID-19 Testing Reimbursement Form certifies by his or her signature that he or she is authorized to sign this form on behalf of the long term care facility, responsible governing board, official and/or contractor(s), and agrees to abide by the specific COVID-19 testing reimbursement guidance provided by the Michigan Department of Health and Human Services.
Individual Name	Individual Title	Date
Completed forms and questions about completing the form can be sent to MDHHS-HFA-COVID-PAYMENT@michigan.gov for AFCs and HFAs and to MDHHS-SNF-TESTING-FINANCIAL@michigan.gov for Nursing Homes.
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender, identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.