Online Application for Eyeglass, Denture, & Hearing Aid Assistance

Today's Date *

First Name *

Last Name *

Maiden Name

Street Address *

Apartment, suite, etc

City *

State *Enter State Abbreviation0 / 2

Zip Code *

Phone Number *

Date of Birth *

Kaw Roll Number *

Currently Employed? *YesNo

If not, enter last date of employment.

Last 4 Digits of Social Security Number *

Number in Family *

Student? *YesNo

Elder? *YesNo

Diabetic? *YesNo

Do you have a chart at Kaw Clinic? *

List Medicare, vision/dental insurance, state assistance, etc.

Type of assistance requested: Please check all that apply./ Eyeglass Wear – ($400 approved every two years)

/ Denture Work – ($500 approved every 3 years)

/ Hearing Aid – ($1,000 approved every 5 years)

I have been informed that any person who knowingly, willfully, and fraudulently provides false information for the purpose of obtaining benefits may be reason for denial. I certify that I have read this application: that I fully understand the application and all information that I have given is true and correct to the best of my knowledge. I also certify that I am an enrolled citizen of the Kaw Nation and that I am not enrolled with another tribe. I understand that dual enrollment is not allowed and that if evidence of such is found, this application will be void and I will be denied services. I also understand this if evidence of dual enrollment is found after services are received, that legal action may be taken to recover any benefits awarded. *

Signature of applicant – Parent/Guardian must sign application for minors