Grant Application – New Hampshire Medical Society

All applications and documentation must be submitted by the 10th of the month for the previous month's expenses in order to meet NHMS submission deadline to DHHS. *

I understand

First Name *

Last Name *

Clinic, practice, office, company name *

EIN/TIN number *

Address (Clinic, practice, office, company) *

City/Town (Clinic, practice, office, company) *

Zip code *

Phone *

Email *

1. Are you an independently owned and operated practice/clinic, NOT affiliated with a hospital community health center (CHC) or federally qualified health center (FQHC) *

Yes

These grants are limited to New Hampshire independent clinical offices/practices, not affiliated with a hospital, CHC or FQHC and their affiliates. Separate COVID-19 vaccine support funding for these groups is being handled through state contracts with the NH Hospital Association and Bi-State Primary Care Association.

2. Has the practice/clinic completed a COVID-19 Vaccine Provider Agreement? *

Yes
No (if no, please state reason below)

If no, please state why

3. Does the practice/clinic currently participate in the NH Immunization Information System (IIS)? *

Yes
No

If Yes: What phase of NHIIS HL7 Onboarding process has the practice/clinic completed? Choose one.

4. What is the practice/clinic submitting for? (check all that apply) *

Clinical Support (for the provision of COVID-19 vaccines)
Administrative Support (for the provision of COVID-19 vaccines)
Equipment (e.g., freezers, refrigerators, data loggers)
Computer Software (e.g., EHR new or upgrade to enable HL7 messaging to NHIIS)

5. File Upload: Please use excel grant template provided at the top of the page, to describe EQUIPMENT, SOFTWARE, OR SUPPLIES and/or CLINICAL AND/OR ADMINSTRATIVE SUPPORT requested. *

Click or drag files to this area to upload. You can upload up to 15 files.

All requests for expense reimbursements must include supporting documentation, including weekly timesheets signed by both employee and direct supervisor specifying vaccine-related hours worked vs total hours, payroll reports verifying pay period, and copies of all paid invoices and receipts.

6. File Upload - Upload receipts (receipts or invoices for reimbursement)

Click or drag files to this area to upload. You can upload up to 15 files.

All requests for expense reimbursements must include supporting documentation, including weekly timesheets signed by both employee and direct supervisor specifying vaccine-related hours worked vs total hours, payroll reports verifying pay period, and copies of all paid invoices and receipts.

7. File Upload - Attach time sheet and supporting documents of clinical or administrative employee’s time.

Click or drag files to this area to upload. You can upload up to 15 files.

All requests for expense reimbursements must include supporting documentation, including weekly timesheets signed by both employee and direct supervisor specifying vaccine-related hours worked vs total hours, payroll reports verifying pay period, and copies of all paid invoices and receipts.

8. Requested total for the current submission (dollar amount) includes all expenses and support related costs *

9. Do you agree to adhere to the quarterly reporting requirements through June 2024 after grant receipt? *

I agree on behalf of the practice/clinic.

10. I declare under penalty of perjury (under the laws of the State of New Hampshire and the United States of America) that the foregoing is true and correct. *

Electronic Signature

Date / Time

Date

Time

Grant Application: Expanding COVID-19 Vaccination Programs for NH Independent Practices

Application Process: