University of Iowa Health Care
Return Completed Form to Lou Ann Montgomery, CNO, T100-GH
Use this form to verify completion and/or request reimbursement for previously approved courses or certification/recertification tuition awards. No persons outside the University are routinely provided this information. Responses to all items are required information. If you fail to provide the necessary information, the University Hospitals and Clinics may be unable to process the reimbursement form. Complete all applicable questions.
Name ______ID# (back of UIHC ID Badge)______
Address ______
Street City State Zip
Do you work in the Department of Nursing? □ Yes □ No
If No, what department do you work in? ______
For what semester are you seeking reimbursement? □ Fall □ Spring □ Summer
Did you receive approval for a tuition award? □ Yes □ No
Is your award for a certification/re-certification? □ Yes □ No
- Certifying agency: ______
Is your award for a college course approved for reimbursement? □ Yes □ No
- Course Number & Title ______Cost ______
- Educational Institution Attended ______
Attach copies of:
1) Transcript or proof of passing grade for each course, OR a copy of certification/recertification
2) Receipt or statement or other proof of tuition paid
I certify that these were my actual tuition expenses, and that none of the expenses for which I hereby request reimbursement have been paid to me or the educational institution by grant, scholarship, gift or other benefit program. I hereby grant Hospital Human Resources, University of Iowa Hospitals and Clinics, permission to verify this information with officials of the educational institution/certifying agency if necessary.
Applicant's Signature ______Date: ______
** Deadline for submission is 30 days following your course or certification completion date.
** Return completed form to Lou Ann Montgomery, CNO, T100-GH
For HR Office Use Only
Approved for payment Denied. Reason ______
Date ______Initial ______