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FORM C-

Walk for Autism – Charleston

Reimbursement Procedures for Alternative Therapies

Please submit documentation for reimbursement to:

Walk for Autism-Charleston

Janine Winn

P.O. Box 60238

N. Charleston, SC 29419-0238

Reimbursement for Alternative Therapies Not Covered By Insurance

Submit an Invoice from Provider. The following information is required:

- The name of the child being served

- The name and address of the provider.

- Itemized listing of services provided

- Dates of Service

- Check number relating to payment

Documentation of payment required within 30 days after sending in your invoice/s i,e., July proof of payment can be submitted with August invoice/s. Submit a copy of the1) the canceled check or 2) the bank statement showing payment which corresponds to the amount on the invoice.

General Guidelines Regarding Scholarship Reimbursement:

1. Recipients can only use up to 20% of their total scholarship on alternative therapies.

2. No cash payments will be reimbursed.

3. Invoices should be received by the 10^th of each month. Reimbursement checks will be written by the 15^th of each month and mailed on the 1^st business day after the 15^th. During holiday or vacation periods an email notification will be sent for any change in this schedule within 7 days of new payment date.

4. All documentation needs to originate from parent/guardian.

Scholarship Awards

You will receive written notification regarding your 2010 scholarship award, a copy of these procedures, and time sheets by June 19^th, 2010. Scholarship awards will be administered as 12 monthly reimbursements. You may submit for a reimbursement above the minimum monthly award. However, any unused portion of your minimum monthly award will return to the organization. If there are any exceptions to this, the attached Request for an Appeal, can be submitted.

I have read and understand the procedures stated above. (Submit signed copy with application.)

______________________________________________

Signature Date