Application for 90 Day, Medical/Dental

Elder Care Program
Application for 90 Day, Medical/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
Date
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:

Eyeglasses-Every two (2) yrs. Assist with only one (1) pair of glasses (no eye exams paid for)Prescriptions- Quarterly assistance on one (1) prescription with valid RX & Invoice (no narcotics)Medical Supplies/Equipment- Quarterly Assistance. Diabetic shoes once yearlyMedical/Hospital Visits-Twice yearly on one (1) service, (Jan-June)(July-Dec) payment after insuranceDental- Twice yearly on one (1) service, (Jan-June) (July-Dec) payment after insurance
Upload and submit current RX ***Photographs of the documents will not be accepted***
Required for medical assistance
Upload and submit valid invoice ***Photographs of the documents will not be accepted***
Required for medical assistance
Tribal Member Signature*

Clear
Today's date*

MonthDayYear
Date
***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
Date
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
Date
Signature*

Clear
Should be Empty:

Elder Care Program

Application for 90 Day, Medical/Dental

Applicant Information

Medical Assistance

AUTHORIZATION FOR RELEASE OF INFORMATION