APPENDIX B American Indian or Alaska Native Family Member (AI/AN) Complete this appendix if you or family members are American Indian or Alaska Native. Submit this with your Application for Health Coverage & Help Paying Costs. 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 monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. 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 Yes Yes 2. Member of a federally recognized If yes, tribe name If yes, tribe name No No 3. Has this person ever gotten a service from the Yes Yes Indian Health Service, a tribal health program, or urban Indian health program, or through a No No referral from one of these programs? If no, is this person eligible to get services If no, is this person eligible to get services from from the Indian Health Service, tribal health the Indian Health Service, tribal health programs, or urban Indian health programs, programs, or Indian health programs, or or through a referral from one of through a referral from one of these programs? programs? Yes No Yes No 4. Certain money received may not be counted for Medicaid or the Children’s Health Insurance $ $ Program (CHIP). List any income (amount and how often) reported on your application that How often? How often? 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 land by the Department of Interior (including reservations and former reservations) Money from selling things that have cultural significance
APPENDIX B American Indian or Alaska Native Family Member (AI/AN) Complete this appendix if you or family members are American Indian or Alaska Native. Submit this with your Application for Health Coverage & Help Paying Costs. 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 monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. NOTE: If you have more people to include, make a copy of this page and attach. AI/AN PERSON 1 AI/AN PERSON 2 1. Name (First name, Middle name, Last name) First Middle First Middle Last Last 2. Member of a federally recognized Yes If yes, tribe name No Yes If yes, tribe name No 3. Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs? Yes No If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral from one of programs? Yes No Yes No If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or Indian health programs, or through a referral from one of these programs? Yes No 4. Certain money received may not be counted for Medicaid or the Children’s Health Insurance 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 land by the Department of Interior (including reservations and former reservations) Money from selling things that have cultural significance $ How often? $ How often?
DCH-1426-Application_for_Health_Coverage__Help_Paying_Costs_with_Appendix_A-B-C_452145_7.docx