Application for Health Insurance Brochure
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Download Application for Health Insurance Brochure
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Payments to the tribe that come from natural resources, usage rights, leases, or royalties Amount __________________________________ Weekly Every two weeks Monthly Other________________________________________________________ Payments from leases or royalties for the use of Indian trust land for natural resources, farming, ranching, or fishing Amount __________________________________ Weekly Every two weeks Monthly Other________________________________________________________ Money from selling things that have cultural value Amount __________________________________ Weekly Every two weeks Person 2: First name Middle name Monthly Other________________________________________________________ Last name Is this person a member of a federally recognized American Indian or Alaska Native tribe Suffix (examples: Sr., Jr., III, IV) Yes No If yes, write the name of the tribe: ________________________________________________________________________________ and the state of the tribe: ___________________________________________________ Has this person ever gotten a service from the Indian Health Service, a tribal health program, or an 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, a tribal health program, or an urban Indian health program or through a referral from one of these programs Does this person get income from any of the sources below Yes No Yes If yes, fill in the amount and frequency below.. Payments to the tribe that come from natural resources, usage rights, leases, or royalties Amount __________________________________ Weekly Every two weeks Monthly Other________________________________________________________ Payments from leases or royalties for the use of Indian trust land for natural resources, farming, ranching, or fishing Amount __________________________________ Weekly Every two w
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