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Tax Information
Important Tax Information for Providers
In order for NorthernBridges to pay you for products or services, we must have your tax identification information. To make this as easy as possible for you, and to be sure that we comply with the Internal Revenue Service (IRS) regulations, we are providing you with the attached Subsitute Form W-9. Please download, complete and mail or FAX the form along with your completed Provider Application Form so that we may have it on file, even if you are exempt from backup withholding.
It is important you make sure the form is complete and correct. We are required to inform you that failure to provide the correct Taxpayer identification Number (TIN)/Name combination may subject you to a $50 penalty assessed by the IRS under section 6723 of the Internal Revenue Code. Please check your records to be sure you are provideing the correct information. If you have any quesitons about this, please contact your accountant, lawyer or tax preparation service.
Only the individual's name to which the Social Security Number was assigned should be entered on the first line.
The name of a partnership, corporation or other entity must be entered on the first line exactly as it was registered with the IRS when the Empoyer Identification Number was assigned.
DO NOT submit your name with a Tax Identification Number that was not assigned to your name. For example, a pharmicist MUST NOT submit his or her name with the Tax Identification Number of a pharmacy he or she is associated with. Failure to provide this information may result in delayed payments or backup withholding. This request is being made at the direction of our third party administrator to ensure that we set up your records with the most current information. Failure to respond in a timely manner may subject you to 29% or more in withholding on each payment or require us to withhold payment of outstanding invoices until this information is received.
Thank you for your cooperation in providing us with this information.
Please mail the completed form along with your Provider Application Form to:
NorthernBridges
Attn: Provider Network Dept.
15954 Rivers Edge Drive
Suite 300 Attn: Provder Network Dept
Hayward, WI 54843
Or fax the form to (715) 934-2268
Note to Adult Family Home (AFH) and Community-Based Residential Facility (CBRF) Providers:
In order to set you up correctly in our accounting system, we require some additional information from AFHs and CBRFs. Please complete the attached Adult Family Home/CBRF Additional Tax Information Form (pdf) or (word doc) and return the form with your W-9.
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