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Contact & Residence

Physician Verification

Physician's verification is requred and will need to be attached at the bottom of the form.

Your Request


By providing my signature below, I authorize the IACA Board of Directors to contact my physician to verify that I am currently undergoing cancer treatment. I certify that I have resided in Interior Alaska for at least 6 months. I certify that I do not have the services for which I am requesting financial assistance available through any federal or state agency, medical insurance, or assistance program. I understand that all decisions of the IACA are final and assistance is determined based on qualification, verification, and availability of funds.

Physician Verification is required.

Please upload your verification below:

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Upload File: Verification
Upload File: Verification

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