Medical Renewal Form Page 8
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9Case name:
Case number:
Date of request:
• If American Indian or Alaska Native and you choose to enroll in plans, use the boxes above to
write your plan choices.
• If American Indian or Alaska Native and you choose not to enroll in a plan, use the lines
below. List who does not want to be enrolled in a medical plan, dental plan, mental health plan
or Coordinated Care Organization:
These people do not want to be enrolled in a Medical Plan:
Name(s) _____________________________________________________________________
These people do not want to be enrolled in a Dental Plan:
Name(s) _____________________________________________________________________
These people do not want to be enrolled in a Mental Health Plan:
Name(s) _____________________________________________________________________
These people do not want to be enrolled in a Coordinated Care Organization:
Name(s) _____________________________________________________________________
If you don’t enroll in a plan, you will be covered by an open card that allows you to get care through
Indian Health Services, Tribal Health Clinics and other providers based on your area. You can let
your worker know at anytime if you decide you would like to be enrolled into a plan.
Tell us about who is helping you
1. Is someone helping you fill out this form?
Yes No
If yes, please tell us about the person.
Name (first, middle initial, last)
Phone number:
This person is my
authorized representative attorney in fact
legal guardian
Healthy Kids grantee or assister OHP outreach and enrollment worker
Other: ________________________ _____________________________
Your signature
Your signature
By signing this form, I affirm under penalty of perjury I have given true and complete information.
I realize that making false statements or hiding information may subject me to state and federal
penalties. I have read this form and understand it. I affirm I have honestly reported the citizenship
of myself and anyone under 18 I am applying for. This is legally binding.
Your signature: _________________________________________
Date: ______________
Best phone number for us to reach you: ______________________________________________
We may be able to send you notices by email. Notices could be a notice like this one or one from
your worker with a question for you. Do you give us permission to send you notices by email?
Yes No If yes, list your email address here: _____________________________________
?
?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 8
OHA 0945 (06/12)
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