Respite Care Reporting Log
The respite care log may be submitted by mailing the form to:
Susan Mast ALS Foundation
2500 Waldorf Court NW, Suite B
Grand Rapids, MI 49544
or via email at: firstname.lastname@example.org.
Reporting period may cover a minimum of 2 weeks and maximum of 1 month. Payment for services will normally be issued within 7 days after receipt of the report form by the Foundation.
** Payment will be issued to agencies for respite care services performed only upon receipt of approved invoice and Respite Care Report form covering the payment period. It is the responsibility of the patient/caregiver to make payment directly to any non-agency providers. Payments by the Foundation for respite care provided by non-agency personnel will only be made directly to patient/primary caregiver.
Click on icon to left to download the report form to complete or make hard copy.
This file may be used to interactiveely create a pdf file for submission.