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City of Prescott

201 S. Cortez Street Prescott, AZ 86303


Healthcare Provider COVID-19 Vaccination Reimbursement

Healthcare providers applying must be vaccinating at least 2,000 people per week on average (as supplies are available) against COVID-19 to be eligible. Only one reimbursement per company is available and the application is open until June 30, 2021. Pharmacies are not eligible.

Address of Company

    Name of Person Applying

    Please upload the company W9

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    Please upload a brief summary of expenses related to administering the vaccine.

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    I attest that the funds received from the City of Prescott will be used for the sole purpose of reimbursing actual expenses incurred by the company I represent in administering the COVID-19 vaccine in the Prescott area.

    Attestation Signature

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    City staff will reach out once the application is submitted to notify of status and to explain next steps.