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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2015 | 4.8 Satisfied (54 Votes) |
The form is intended for original NANA shareholders (Class A, B, C, or D) applying for emergency medical assistance.
Applicants must submit a doctor's release and a completed W-9 form along with the Emergency Medical Assistance Form.
For assistance, applicants can contact NANA Regional Corporation at (907) 442-3301 or (800) 478-3301.
Checks for medical assistance are made payable to the medical facility where the patient is receiving care.
The W-9 form requires individuals to provide their correct TIN to avoid backup withholding on payments.
Payments may be subject to backup withholding if the TIN is not provided or certified correctly on the W-9 form.
Certain payees may be exempt from FATCA reporting; this exemption must be indicated on the W-9 form if applicable.
