2015 Cover Montana Outreach and Enrollment Summit
Summit Scholarship Information
The Montana Primary Care Association and Cover Montana to provide scholarships for the 2015 Outreach
and Enrollment Summit. There are a limited number of scholarships available and they are available on a
first-come first-serve basis.
Scholarships are available to help individuals and organization participate in the Montana Outreach and
Enrollment Summit. While there is not an application, there are a limited number of scholarships available.
The Montana Primary Care Association and Cover Montana urge organizations and individuals to apply only
if a scholarship is required for participation in the Summit.
There is not a registration fee to participate in the 2015 Summit and scholarships will reimburse up to $300
in travel and lodging expenses. More details about the required documentation and reimbursement
process are included on page 2 of this document. Please review page 2 of this document prior to requesting
a scholarship.
Please note: If you need a scholarship, you must inform MPCA that you are requesting a scholarship to
ensure that they are still available. To request a scholarship, please contact Courtney Buys,
cbuys@mtpca.org or (406) 465-3267.
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2015 Montana Outreach and Enrollment Summit Scholarship
The Montana Primary Care Association will reimburse up to $300 in travel and lodging expenses for
participation in the 2015 Summit. Travel will be reimbursed at a rate of $.0575/mile and a receipt is not
required. Lodging will be reimbursed and a receipt is required. Receipts must be attached to this form.
MPCA will only reimburse up to $300 for travel, lodging, or a combination of both.
Please send the completed form and receipts via mail or email to Barb Leake at the Montana Primary Care
Association, 1805 Euclid Ave. Helena, MT 59601 or bleake@mtpca.org.
Name of the organization or individual to be reimbursed: _______________________________
Street Address: ________________________________________________________________
City, State, Zip: ________________________________________________________________
Email: _________________________________________ Phone: ________________________
Date:
Internal Use Only
Description of Reimbursement:
Amount
QB Account
QB Class
1
2
3
4
Travel from ________________ to Helena and back
=__________________miles x $.0575 = _______________
Total Cost to be Reimbursed
$
Signature
MPCA Authorization Signature
Hotel receipt is required for reimbursement
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