Please complete all required fields!
These Items Will Be Needed For This Online Application:
Pregnant women also need to submit:
College Students also need to submit the following:
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.
MAILING & PHYSICAL ADDRESS
APPLICATION FOR TRIBAL HEALTH PAID CARE
(paid care is only if you live on the reservation or for CSKT members surrounding counties)
CSKT Enrolled Member
Other Federally Recognized Enrolled Member
Other Federally Recognized Descendant
Congrats you have completed the form please click submit!
PO Box 880 (MAILING) | 35401 Mission Drive (PHYSICAL) | St. Ignatius, MT 59865
Phone: (406) 745-3525 | Email: email@example.com | www.cskthealth.org