Tuberculosis (TB) Treatment Assistance - Enrollment
Enroll in the American Lung Association in Wisconsin’s TB Treatment Assistance Program by filling out the TB Treatment Assistance Program Enrollment and Agreement Form. Once you enroll, you will need to review and sign the agreement on an annual basis. Additionally, please inform us of any contact information changes.
First-Time enrollees: a completed W-9 is required to be on file with the Lung Association for all check/reimbursement processing. Please submit completed W-9 along with the Enrollment form.
Send, email or fax the Enrollment and Agreement Form to:
American Lung Association in Wisconsin
TB Treatment Assistance Program
13100 W. Lisbon Road, Suite 700
Brookfield, WI 53005
FAX: (262) 781-5180
After the American Lung Association in Wisconsin receives your enrollment and agreement form, you will receive:
- Welcome and confirmation letter
- Forms - Forms - reimbursement request, purchase log, disbursement record, special request and W-9. (Make copies of the forms and retain the originals for future use.)
Page Last Updated: March 21, 2018