Application for 90 Day Medical or Dental

Elder Care Program
Application for 90 Day Medical or Dental

(Must be 55 or older and an active client)
Applicant Information
Name

First NameLast Name
CDIB#
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical Assistance

One (1) request per assistance, up to $200 on current amount Must provide current RX & Invoice for all medical assistance. ***No cosmetic procedure paid for on Medical/Dental***
Choose one:
Upload and submit current RX ***Photographs of the documents will not be accepted***

Browse Files
Required for medical assistance Cancelof
Upload and submit valid invoice ***Photographs of the documents will not be accepted***

Browse Files
Required for medical assistance Cancelof
Tribal Member Signature
Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
***Elder Care Program does not reimburse any services provided***
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize you to release any information from any medical facility, institutions, the Social Security Administration, any local, State, or Federal Law Enforcement Agency, or any other agency. I understand that his information is to be held confidential by all parties.
Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
The information is to be released from:
Name of Agency
ATTN:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Information to be released includes:
This authorization will terminate one year from the date of my signature. It is further understood that I may revoke this authorization any time by written request except to the extent that action has been taken in reliance theron.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty:

Elder Care Program

Application for 90 Day Medical or Dental

Applicant Information

Medical Assistance

AUTHORIZATION FOR RELEASE OF INFORMATION