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Tribal Healthcare Expense/Reimbursement Application

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PROGRAM OVERVIEW AND REQUIREMENTS
This program provides funding assistance to eligible tribal citizens for healthcare-related expenses under the Nation’s Healthcare Policy. The following requirements and restrictions apply:

Eligible Dates for Expenses:
- Costs must have been incurred between January 1, 2025, and December 31, 2025.

Previous Year Program Deadline:
- All 2024 applications must be submitted by January 31, 2025, at 4:00 PM Pacific Standard Time.

Eligibility
- Must be an Enrolled KDWN Tribal Citizen.

Documentation Requirements:
All applications must include receipts or proof of expense clearly identifying the incurred cost. Examples include:
- RX Customer Copy
- Receipts of payment
- Reimbursements will only be issued directly to the tribal citizen who incurred the expense and submitted the request. Reimbursement Payments to third parties are not allowed.

Limitations and Prohibited Items:
- a) Medically prescribed marijuana in any form.
- b) Medically prescribed opioids are prohibited from coverage.
- c) Non-medically necessary cosmetic or elective procedures are not allowable.
- d) Any single medical expense exceeding $15,000 requires Tribal Council authorization.
- e) Payments require at least five (5) business days for processing.
- f) Coverage for prescription eyewear is limited to two pairs of glasses or a 12-month supply of
contacts per funding cycle.
- g) Fertility and Hormone Treatments: (For more detail review the Healthcare Funding Policy)

Processing Time:
- Approved payments will be processed within five (5) business days.

Incomplete Applications:
- Applications that are incomplete will be denied and returned.

Submission Information:
- Email completed applications to: [email protected]
- Fax to: (530) 387-3109
- Mail to: Kletsel Dehe Wintun Nation P.O. Box 1630, Williams, CA 95987
- For program-related questions, contact the Tribal Office at: (530) 419-5058

Please enable JavaScript in your browser to complete this form.
Physical Address
Mailing Address
I am requesting healthcare funding assistance for:
Do you have healthcare insurance coverage?
Are you a Patient of NVIH?
Are you a patient of any other tribal healthcare clinic?
Please Check the Category of the Expense and attach proof of cost or expense along with this form.
(Applications listing “Other” may be subject to additional administrative review before approval)
$0.00
Click or drag files to this area to upload. You can upload up to 8 files.

Payee Information (If Not Reimbursement Request)

(Medical Practice Name)
Physical Address
(Medical Practice Physical Address)
Mailing Address
(Medical Practice Primary Billing Mailing Address)
(Medical Practice Phone)
(Medical Practice Email)

APPLICATION CERTIFICATION:

I certify that the information provided in this application is accurate and complete to the best of my knowledge. By signing below, I confirm that I have not and will not submit the same expenses for reimbursement to any other third-party payer, including other tribal health programs, PRC, or private insurance. I understand that false statements or duplicate requests may result in termination of assistance and other sanctions under tribal law.
Clear Signature