Emergency Medical Fund – Tebughna Foundation

Emergency Medical Fund

Name of Patient *

First

Last

Date of Birth *

Date of Medical Treatment *

Patient's Hospital/Clinic *

Hospital Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is the patient: *

TNC Shareholder
NVT Tribal Citizen
None of the above

Health Insurance Provider *

Your Information

Receipient of Funds *

First

Last

How are you related to the patient? *

Self
Other

Phone *

Email *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Section Divider

Amount Requested *

Reported Expenses *

File Upload *

Click or drag files to this area to upload. You can upload up to 5 files.

Please provide documentation of hospitalization (bills, receipts, etc.).

Signature *

Clear Signature