Medicaid And Kid Care Chip Renewal Form Page 10

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American Indian or Alaska Native family
Attachment B
member (AI/AN)
To help you fill out Section 5, page 6
Tell us about your American Indian or Alaska Native family member(s)
American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban
Indian health programs. They may not have to pay co-pays and may get special monthly enrollment periods.
If more than two people are American Indian or Alaska Native, make a copy of this page.
1.
Name (first, middle, last & suffix):
Has this person ever received a service from the Indian Health Service, a tribal health program, or urban Indian health program?
Yes
No
If no, does this person qualify to get these services?
Yes
No
List any income that includes money from these sources:
$
How much income?
Payments from a tribe for natural resources, usage rights, leases, or royalties
How often?
Payments from natural resources, farming, ranching, fishing, leases, or royalties from
land designated as Indian trust land by the Department of Interior (including reservations and
Weekly
Twice a month
former reservations)
Every two weeks
Yearly
Money from selling things that have cultural significance
Monthly
2.
Name (first, middle, last & suffix):
Has this person ever received a service from the Indian Health Service, a tribal health program, or urban Indian health program?
Yes
No
If no, does this person qualify to get these services?
Yes
No
List any income that includes money from these sources:
$
How much income?
Payments from a tribe for natural resources, usage rights, leases, or royalties
How often?
land designated as Indian trust land by the Department of Interior (including reservations and
Weekly
Twice amonth
former reservations)
Yearly
Money from selling things that have cultural significance
Monthly
?
10
Questions?
Call our customer service center at 1-855-294-2127 (TTY/TDD: 1-855-329-5204).
The call is free. You can call 7:00 a.m. to 6:00 p.m. Monday to Friday. Or visit

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