Exhibit D-1

(*For use only by Nursing Homes that have formally executed the OPB Coronavirus Relief Fund Terms and Conditions for Nursing Home Facilities
(“Grant Agreement”) and received a Funding Announcement from OPB)

Georgia Coronavirus Relief Fund Testing Grant

CLIA Waiver Nursing Home Testing Invoice

Facility Name:
License Number:
CLIA Number:
Billing Period Beginning:
Billing Period Ending:

Please provide details below on who should be contacted if there are questions about this submission:
Contact Name:
Contact Title:
Contact Email:
Contact Phone:

Commercial Lab/PCR Testing

# of Employee Tests - Total Reimbursement $ -

Antigen Testing
# of Employee Tests - Total Reimbursement $ -
Reimbursement Rate $ 51.31

Total Grant Reimbursement $ -

Checklist/Affirmation
By making this submission, each provision in the previously submitted Attestation is hereby affirmed.

Printed Name/Signature:
Title of Signatory:
Date of Submission:

THE NAMES, ADDRESSES, SOCIAL SECURITY NUMBERS, AND MEDICARE, MEDICAID INSURANCE NUMBERS AND OTHER IDENTIFYING
INFORMATION OF ANY PERSONS (PATIENTS OR STAFF) CONTAINED IN ANY DOCUMENTATION MUST BE REMOVED FROM THE
DOCUMENTATION PRIOR TO SUBMISSION OR THE CLAIM WILL NOT BE PROCESSED. THE FACILITY MUST, HOWEVER, RETAIN
DOCUMENTATION SHOWING ALL SUCH NAMES TO PERMIT STATE AND FEDERAL AUDITS.

Include all supporting documentation that clearly sets forth expenditures being claimed for reimbursement. Reimbursement will only be paid to
the Grantee/Nursing Home. All documentation is incorporated into the Grant Agreement by reference.
 Exhibit D-2
(*For use only by Nursing Homes that have formally executed the OPB Coronavirus Relief Fund Terms and Conditions for Nursing Home
Facilities (“Grant Agreement”) and received a Funding Announcement from OPB)

Georgia Coronavirus Relief Fund Testing Grant

Summary of Antigen Testing

Facility Name:
License Number:
CLIA Number:
Billing Period Beginning:
Billing Period Ending:

Summary of the Number of Antigen Tests Reported on the DPH Spreadsheets for the Days in the Billing Period

Date of the DPH Report - Day Reimbursement

of the Month Total Employee Tests (1) ($51.31 per test)
1 $ -
2 $ -
3 $ -
4 $ -
5 $ -
6 $ -
7 $ -
8 $ -
9 $ -
10 $ -
11 $ -
12 $ -
13 $ -
14 $ -
15 $ -
16 $ -
17 $ -
18 $ -
19 $ -
20 $ -
21 $ -
22 $ -
23 $ -
24 $ -
25 $ -
26 $ -
27 $ -
28 $ -
29 $ -
30 $ -
31 $ -
Total Tests - $ -

(1) This entry should reflect the number of "Y" responses in column "M" of the DPH
Spreadsheet (Healthcare workers include volunteers, contractors, etc. per the QSO-20-38-
NH definition of staff)
(2) This entry should reflect the number of "Y" responses in column "N" of the DPH
Spreadsheet
(3) This sum should equal the total number of Antigen Tests reported on the respective
DPH Spreadsheet

Include all supporting documentation that clearly sets forth expenditures being claimed for reimbursement. Reimbursement will only be
paid to the Grantee/Nursing Home. All documentation is incorporated into the Grant Agreement by reference.
 Exhibit D-3
(*For use only by Nursing Homes that have formally executed the OPB Coronavirus Relief Fund Terms and Conditions for Nursing Home Facilities (“Grant Agreement”)
and received a Funding Announcement from OPB)

Georgia Coronavirus Relief Fund Testing Grant

Summary of PCR Tests (Commercial Labs)

Facility Name:
License Number:
CLIA Number:
Billing Period Beginning:
Billing Period Ending:

Invoice Summary for PCR Tests Processed by Commercial Labs for the Billing Period

Total Employee Test Maximum Grant Amount Grant Reimbursement

Invoice Date Invoice Number Total Employee Tests (1) Invoice Cost (2) (3) Amount
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
jk $ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
$ - $ -
Total - $ - $ - $ -

(1) This entry should reflect the number of employee tests on the invoice (Healthcare workers include volunteers, contractors, etc. per the
QSO-20-38-NH definition of staff)
(2) This entry should reflect the total cost per the invoice for the employee tests
(3) Maximum reimbursement amount (Number of Tests x Reimbursement Limit) Limit Per Test $ 110

Include all supporting documentation that clearly sets forth expenditures being claimed for reimbursement. Reimbursement will only be paid to the Grantee/Nursing
Home. All documentation is incorporated into the Grant Agreement by reference.