Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 15
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29ATTACHMENT A
AMERICAN INDIAN/ALASKA NATIVE HOUSEHOLD
MEMBER INFORMATION
(Required only for Medical Assistance)
Case Name: ___________________________________ Case#: __________________________
D34314000241529
Complete this form if you or family members are American Indian or Alaska Native.
Submit this with your application for medical assistance.
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 also may not have to pay cost sharing and may get special month enrollment periods.
NOTE: If you have more people to include, make a copy of this page and attach.
AI/AN PERSON 1
AI/AN PERSON 2
First
Middle
First
Middle
1. Name
(First name, Middle name, Last
name
Last
Last
2. Member of a federally recognized
Yes
No
Yes
No
tribe?
If yes, tribe name:
If yes, tribe name:
____________________________
______________________________
3. Has this person ever gotten a
Yes
No
Yes
No
service from the Indian Health
Service, a tribal health program, or
If no, is this person eligible to get
If no, is this person eligible to get
urban Indian health program, or
services from the Indian Health
services from the Indian Health
through a referral from one of
Service, tribal health programs,
Service, tribal health programs,
these programs?
urban Indian health programs or
urban Indian health programs or
through a referral from one of
through a referral from one of
these programs?
these programs?
Yes
No
Yes
No
4. Certain money received may not
$ ____________________________
$ ____________________________
be counted for Medicaid or the
Children’s Health Insurance
How often? ____________________
How often? ____________________
Program (CHIP). List any income
(amount and how often) reported
on your application that includes
money from these sources:
Per capita payments from a tribe
that come from natural
resources, usage rights, leases,
or royalties.
Payments from natural
resources, farming, ranching,
fishing, leases, or royalties from
land designated as Indian trust
land by the Department of the
Interior (including reservations
and former reservations).
Money from selling things that
have cultural significance.
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals with speech and/or hearing
impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
Page 15
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