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?
APPENDIX D Flint Water Group By completing these questions, you are requesting enhanced Medicaid coverage for individuals due to potential exposure to lead in the city of Flint water system. Answer the questions below for anyone who is currently under age 21, pregnant, or pregnant within the last 2 months. Please list anyone who consumed from the Flint water system and lived, worked, or received childcare or education at an address that was served by the Flint water system at any time from April 2014 through the present. Between April 2014 and present day, did any applicant live at an address that was served by the Flint water system? Please include all addresses and indicate all applicants who lived at each address. Address served by the Flint water system Names of applicants who lived at the address Dates applicants lived at the address (From/To) Between April 2014 and present day, did any applicant work at an address that was served by the Flint water system? Please include all addresses and indicate all applicants who worked at each address. Address served by the Flint water system Names of applicants who worked at the address Dates applicants worked at the address (From/To) Between April 2014 and present day, did any applicant attend school or receive childcare at an address that was served by the Flint water system? Please include all addresses and indicate all applicants who attended school or received childcare at each address. Address served by the Flint water system Names of applicants who attended school/childcare at the address Dates applicants attended school/childcare at the address (From/To) You may be asked to provide verification or proof that you consumed water and lived, worked or received regular services (attend childcare or school) at an address that was served by the Flint water system from April 2014 through present day. Any knowingly false information or statements provided may be reviewed by the Office of Inspector General.