{"id":2318,"date":"2019-04-19T12:23:46","date_gmt":"2019-04-19T16:23:46","guid":{"rendered":"https:\/\/www.bumc.bu.edu\/hematology\/?page_id=2318"},"modified":"2019-07-10T14:55:51","modified_gmt":"2019-07-10T18:55:51","slug":"reimbursement-requests","status":"publish","type":"page","link":"https:\/\/www.bumc.bu.edu\/hematology\/reimbursement-requests\/","title":{"rendered":""},"content":{"rendered":"<h4 style=\"text-align: center;\"><span style=\"color: #003366;\"><strong>Reimbursement Requests<\/strong><\/span><\/h4>\n<h4 style=\"text-align: center;\"><span style=\"color: #003366;\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_6' ><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/hematology\/wp-json\/wp\/v2\/pages\/2318' data-formid='6' >\n                        <div class='gform-body gform_body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_6_13\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_13\"><label class='gfield_label gform-field-label' for='input_6_13' >Submission Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_13' id='input_6_13' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_13_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_13_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_13' class='gform_hidden' value='https:\/\/www.bumc.bu.edu\/hematology\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_5\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_5\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_5'>\n                            \n                            <span id='input_6_5_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.3' id='input_6_5_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_5_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_5_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_5.6' id='input_6_5_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_5_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_6_20\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_20\"><label class='gfield_label gform-field-label' for='input_6_20' >Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_6_20' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_22\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_22\"><label class='gfield_label gform-field-label' for='input_6_22' >Mailing address (Where check should be mailed to)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_6_22' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_16\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_16\"><label class='gfield_label gform-field-label' for='input_6_16' >Role<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_6_16' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Faculty (MD)' >Faculty (MD)<\/option><option value='Faculty (PhD)' >Faculty (PhD)<\/option><option value='Faculty (NP)' >Faculty (NP)<\/option><option value='Faculty (Genetic Counselor)' >Faculty (Genetic Counselor)<\/option><option value='Staff' >Staff<\/option><\/select><\/div><\/li><li id=\"field_6_10\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_10\"><label class='gfield_label gform-field-label' for='input_6_10' >Expense Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_6_10' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Travel' >Travel<\/option><option value='Business' >Business<\/option><\/select><\/div><\/li><li id=\"field_6_14\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_14\"><label class='gfield_label gform-field-label' for='input_6_14' >Expense Date(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_14' id='input_6_14' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_14_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_14_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_14' class='gform_hidden' value='https:\/\/www.bumc.bu.edu\/hematology\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_21\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_21\"><label class='gfield_label gform-field-label' for='input_6_21' >Expense Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_6_21' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_24\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_24\"><label class='gfield_label gform-field-label' for='input_6_24' >Is the amount requested over the $1,000.00 provided in CME funding (Clinical faculty only)?  (Y\/N)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_24' id='input_6_24' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_6_19\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_19\"><label class='gfield_label gform-field-label' for='input_6_19' >If indicated &quot;yes&quot; on the previous question, please indicate how much over $1,000.00 you are requesting<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_6_19' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_23\"  class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_23\"><label class='gfield_label gform-field-label' for='input_6_23' >Would you like to request approval for additional funding? (Y\/N)<\/label><div class='ginput_container ginput_container_select'><select name='input_23' id='input_6_23' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_6_27\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_27\"><label class='gfield_label gform-field-label' for='input_6_27' >If research related expense, should this be charged to a grant or recruitment fund? (Y\/N)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_6_27' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_6_26\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_6_26\"><label class='gfield_label gform-field-label' for='input_6_26' >If you indicated &quot;yes&quot; on the previous question, please provide the grant number or recruitment fund cost center to be charged.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' 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