2024 Assembly Reimbursement Form

2025 Assembly Reimbursement Form

UCA will reimburse attendees up to $1000 to cover travel expenses. All expense reimbursement forms and receipts MUST be received by August 11, 2025, to receive reimbursement.

I attended *

the Clinical Advisory Group
the Delegates Council
the Strategic Advisory Group

I would like to *

Consider waiving your reimbursement so funds may be used in other pursuits for the advancement of the field of Urgent Care.

Expense Reimbursement - UCA will reimburse travel expenses up to $1000.

Gather ALL your receipts BEFORE you start.

Travel receipts may include airfare; travel to/from airport; and the rooms from the event hotel. Mileage, if submitted rather than airfare, is reimbursed at $0.70/mile.

All expense reimbursement forms and receipts MUST be received by August 11, 2024, to receive reimbursement.

Transportation Expenses Description

If mileage expense, calculate miles x $.70 for total amount.

Airfare Expenses Description

Hotel Expenses Description

Total $$ Amount of Transportation Expenses

If mileage expense, calculate miles x $.70 for total amount.

Total $$ Amount of Airfare Expenses

Total $$ Amount of Hotel Expenses

Receipt Upload *

Click or drag files to this area to upload. You can upload up to 10 files.

Upload all travel receipts, with AMOUNTS and DESCRIPTIONS clearly notated.

Name *

First

Last

Organization *

Email *

Authorization for Direct Deposit via ACH

Direct Deposit via Automated Clearing House (ACH) is the deposit of funds to a consumer's account for payroll, employee expenses reimbursement, government benefits, tax and other refunds, and annuities and interest payments.

Urgent Care Association is referred to as UCA in this form.

Bank Name *

Account Number *

Account Type *

Checking
Savings

Bank Routing Number *

Check all to agree to the terms of this Direct Deposit authorization. *

I authorize UCA to electronically credit my account (and if necessary, debit my account to correct erroneous credits).*
I understand this authorization will remain in full force and effect until I notify UCA in writing (via email) that I wish to revoke this authorization.
I understand that UCA requires at least one week prior notice in order to cancel this authorization.**
I agree that ACH transactions I authorize will comply with all applicable laws.

* The National Automated Clearing House Association (NACHA) Operating Rules do not require the consumers express authorization to initiate reversing entries to correct erroneous transactions. however, Originators should consider obtaining express authorization of debits or credits to correct errors.

** Written credit authorization must provide that the receiver may revoke authorization only by notifying the Originator in the time and manner stated in the authorization. The reference to notification should be filled with a statement of the time and manner that notification must be given in order to provide the company a reasonable opportunity to act on it.

2025 Assembly Reimbursement Form

Expense Reimbursement - UCA will reimburse travel expenses up to $1000.

Authorization for Direct Deposit via ACH

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