{"id":5155,"date":"2024-10-09T13:52:29","date_gmt":"2024-10-09T17:52:29","guid":{"rendered":"https:\/\/www.bumc.bu.edu\/pulmonarycenter\/?page_id=5155"},"modified":"2024-11-04T12:50:09","modified_gmt":"2024-11-04T17:50:09","slug":"bmc-pulmonary-section-reimbursement-request","status":"publish","type":"page","link":"https:\/\/www.bumc.bu.edu\/pulmonarycenter\/definition\/administrative-resources\/bmc-pulmonary-section-reimbursement-request\/","title":{"rendered":"BMC Pulmonary Section Reimbursement Request"},"content":{"rendered":"<p>&nbsp;<\/p>\r\n<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 gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_15' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">BMC Section Reimbursement Form<\/h2>\n                            <p class='gform_description'>Pulmonary Section Reimbursement Requests. Please utilize this form for any expenses covered by the BMC Clinic\/Section. Such as credentialing  (License, DEA, MA controlled substance registration, etc.) and CME (Travel, conference registration fees, training, etc.) expenses<\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_15'  action='\/pulmonarycenter\/wp-json\/wp\/v2\/pages\/5155' data-formid='15' >\n                        <div class='gform-body gform_body'><div id='gform_fields_15' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_15_1\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_1\"><h3 class=\"gsection_title\">Personal Information<\/h3><\/div><fieldset id=\"field_15_35\"  class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_35\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><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_15_35'>\n                            \n                            <span id='input_15_35_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.3' id='input_15_35_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_15_35_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_15_35_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_35.6' id='input_15_35_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_15_35_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_15_36\"  class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_36\"><label class='gfield_label gform-field-label' for='input_15_36' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_36' id='input_15_36' type='text' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_15_43\"  class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_43\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_15_43' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_15_43_1_container' >\n                                        <input type='text' name='input_43.1' id='input_15_43_1' value=''    aria-required='true'    \/>\n                                        <label for='input_15_43_1' id='input_15_43_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_15_43_2_container' >\n                                        <input type='text' name='input_43.2' id='input_15_43_2' value=''     aria-required='false'   \/>\n                                        <label for='input_15_43_2' id='input_15_43_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_15_43_3_container' >\n                                    <input type='text' name='input_43.3' id='input_15_43_3' value=''    aria-required='true'    \/>\n                                    <label for='input_15_43_3' id='input_15_43_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_15_43_4_container' >\n                                        <input type='text' name='input_43.4' id='input_15_43_4' value=''      aria-required='true'    \/>\n                                        <label for='input_15_43_4' id='input_15_43_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_15_43_5_container' >\n                                    <input type='text' name='input_43.5' id='input_15_43_5' value=''    aria-required='true'    \/>\n                                    <label for='input_15_43_5' id='input_15_43_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_43.6' id='input_15_43_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_15_42\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_15_42\"><h3 class=\"gsection_title\">Reimbursement Request<\/h3><div class='gsection_description' id='gfield_description_15_42'>Credentialing for faculty only (License, DEA, MA controlled substance registration, etc.) and CME for faculty &#038; fellows. Travel, conference registration fees, etc.) expenses.<\/div><\/div><fieldset id=\"field_15_38\"  class=\"gfield gfield--type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_15_38\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Expenses<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_15_38'>Please List Each Expense Separately. ( i.e. Registration $100, License renewal $100, Accommodations $100). \nTIP: Use toggle on righthand side to add another line expense. <\/div><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Expense<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Amount<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_38_cell1 gform-grid-col' data-label='Expense'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_15_38\" aria-label='Expense, Row 1' data-aria-label-template='Expense, Row {0}' type='text' name='input_38[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_38_cell2 gform-grid-col' data-label='Amount'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_15_38\" aria-label='Amount, Row 1' data-aria-label-template='Amount, Row {0}' type='text' name='input_38[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 20)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 20)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_15_41\"  class=\"gfield gfield--type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  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