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Medicare Rural Hospital Flexibility Program (Flex)
Peer to Peer Exchange and Professional Development Program
for ND CAHs and CAH-owned RHCs
APPLICATION
Date
Applicant:
Organization
Address
City
Zip
Contact Name
Contact Title
Email
Phone
Name of person(s) involved in exchange:
What community would you like to conduct the peer to peer exchange with?
Location of peer to peer exchange (check one):
I/We want to visit the community/organization listed above
I/We want to bring someone from the community listed above to our community/organization
Peer to peer exchange Request:
Describe the peer to peer exchange mentoring activity for which funding is requested.
Anticipated date(s) of exchange:
Intended outcome:
Total estimated funding request:
Itemized request:
Allowable expenses -
Round-trip ground mileage between your organization and the mentor location, calculated at the current IRS standard mileage rate for business travel. A screenshot of roundtrip mileage from Google Maps or MapQuest is required for mileage verification.
Lodging limited to reasonable accommodations and only those nights necessary to meet the needs of the proposed exchange. Maximum three nights per person for two-day exchange. Zero balance hotel receipt with one guest in the room required for reimbursement.
Per Diem will be reimbursed at the current ND state standard rate.
Mileage $ (calculated at current IRS standard mileage rate for business)
Lodging $ (maximum 3 nights/person; limited to length of exchange)
Per Diem $ (calculated at ND standard rate)
Organizations receiving travel support are required to complete an outcome report upon exchange completion.
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