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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Part 2, Chapter 4:  Manual Appendix A

APPLICATION FOR TREATMENT AT REMOTE PHS FACILITY
UNDER 42 U.S.C. §251
(Section 324 Partnership for Health Amendment)

I, ______________________________________
                              (Name)

Address:________________________________________________________________________________________

Name & Address of Employer ________________________________________________________________________

Employee Identification* _____________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

hereby apply for medical care for:

____ Myself and/or ____ My dependents as follows:

Name Relationship
______________________________________ ______________________________________
______________________________________ ______________________________________
______________________________________ ______________________________________
______________________________________ ______________________________________
______________________________________ ______________________________________
______________________________________ ______________________________________
(Use reverse side if additional space is needed.)

I understand that I will be charged for the care furnished, at the current Bureau of the Budget rates, and that a false or fraudulent statement is punishable under 18 U.S.C.§100].

_____________________________________________
(Signed)                         ;    

* Show credentials, government drivers license, building pass, employees' assn. or credit union membership card, and/or Social Security No., or certification by employing unit or official.


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