Native Traditional Healing Benefit Reimbursement Form printable pdf download

Please submit ORIGINAL completed claim to:

Navajo Nation Employee Benefit Program

PO Box 1360

Window Rock, AZ 86515

NATIVE TRADITIONAL HEALING BENEFIT REIMBURSEMENT FORM

EMPLOYEE’S STATEMENT (To be completed by Employee)--BLACK INK only

Employee’s Name: ___________________________________Health Insurance Member ID No.: ___________________

(Do not indicate SS No.)

Names of Covered Member(s) Who Received Services: ____________________________________________________

_________________________________________________________________________________________________

Mailing Address: ___________________________________________________________________________________

 NAVAJO NATION

 ENTERPRISE OR CHAPTER_____________________________________

Employer:

(Name must be indicated)

I certify that the healing ceremony indicated below was performed for me and/or my covered dependents by a commonly

recognized or authorized Native Traditional Practitioner. I hereby request reimbursement in the amount of $___________

for the ceremony.

I authorize the Native Traditional Practitioner to verify information contained only on this form.

(Receipts not required)

Traditional Practitioner(s) $_____________

Materials $_____________

Food $_____________

(Please Itemize)

NATIVE TRADITIONAL PRACTITIONER’S STATEMENT (To be completed by Native Practitioner)

Native Traditional Practitioner’s Name (Please Print): ______________________________________________________

Census No. ____________Tribal Enrollment Affiliation _____________________Telephone No.: ___________________

(Optional)

Mailing Address (

): _________________________________________________________

No General Delivery or Trading Post

Street Address or Post Office Box

City

State

Zip

CEREMONY PERFORMED – Check appropriate box(s)

 DIAGNOSIS  PROTECTION/PREVENTION  BLESSING WAY  OTHER ____________________________

(Name of ceremony must be indicated)

Date(s) Ceremony was Performed _____________________________________

(Month/Day/Year REQUIRED)

(Separate claim form must be submitted for each date of service unless one ceremony lasts for more than one day, consecutively)

 EMPLOYEE

 EMPLOYEE’S SPOUSE

 EMPLOYEE’S CHILD(REN)

PATIENT(S)

(must match above)

Native Traditional Practitioner’s Recommendations or Comments (Optional):

_________________________________________________________________________________________________

_____________________________________________________________

___________________

Signature (THUMB PRINT) of Native Traditional Practitioner

Date

(REQUIRED to validate claim)

EMPLOYEE BENEFIT PROGRAM’S REVIEW (To be completed by EBP)



Authorized for Payment

01/11

Native Traditional Healing Benefit Reimbursement Form

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