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Tribal Heath Patient Registration Online Form

These Items Will Be Needed For This Online Application:

  • Proof of Tribal Enrollment or Descendancy (official letter from the tribe)
  • Birth Certificate
  • Social Security Card
  • 1 Item for proof of residency (electric bill, rent/lease receipt, valid MT Driver's license with your current physical address or a voter registration card with your current address and/or residential phone bill dated within the last 30 days).
  • Medicaid, Medicare and/or HMK Card OR letter of denial (copy both sides of the card)

Pregnant women also need to submit:

  • Statement from your OB-GYN with Due Date

College Students also need to submit the following:

  • Student status verification (official letter/official transcripts from the institute verifying full-time student status and duration of attendance)
  • Contract Health Service eligibility letter from home reservation

 

If all required documents are NOT submitted with your application your eligibility status will be "Direct Care Only".  An Eligibility Determination for "Purchase Referred Care" cannot be made until your application is complete. This means there will be no medical services paid by THPC medical treatment received outside of our facility.

RECIPIENT INFORMATION


 

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MAILING & PHYSICAL ADDRESS


 

Please provide your mailing address!

City is required!

You must select a state!

Zip code is required!

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CONTACT INFORMATION


 

A phone number is required!

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Please designate a Primary Care Provider!

You must provide an emergency contact!

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You must provide a phone number for your emergency contact!

Select one!

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INSURANCE INFORMATION


 

Please select one.

Please select one.

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Upload Documents


 

Upload Documents

Please provide proof of enrollment!

Please provide a copy of your Birth Certificate!

Please provide a copy of your Social Security Card!

Please provide proof of residency!

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Pregnant women also need to submit:

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College Students also need to submit the following:

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APPLICATION FOR TRIBAL HEALTH PAID CARE

(paid care is only if you live on the reservation or for CSKT members surrounding counties)


 

Please answer Yes or No.

APPLICATION FOR TRIBAL HEALTH PAID CARE

(paid care is only if you live on the reservation or for CSKT members surrounding counties)


 

Please select one!

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Congrats you have completed the form please click submit!

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