SDPI-MedAssist. Rev. 11.06.2019/VDF
FORT SILL APACHE TRIBE
DIABETES MEDICAL ASSISTANCE
APPLICATION
Name: ________________________________ Enrollment #:___________ Male: ______ Female: ______
Mailing Address: _____________________________ City: ______________ State: ______ ZIP: ________
Birthdate: ____________________ Age: _________ Social Security #: ____________________________
Home Number: ___________________________ Cell Phone Number: ____________________________
ARE YOU DIABETIC? YES _____ NO _____
Please check ONE of the items that you would like to be assisted with. The Special Diabetes Program can
only pay up to $200.00 towards the checked item below:
_____ EYEGLASSES _____ BLOOD PRESSURE MONITOR _____ DIABETIC SHOES
_____ WALKER/ROLLATOR _____ WHEELCHAIR/CANE _____ LANCETS/SYRINGES
_____ SHOWER CHAIR _____ BLOOD GLUCOSE MONITOR _____ OTHER EQUIPMENT
To be eligible for this type of assistance, the client must complete this application, provide a copy of
your CDIB and submit a written prescription from a physician stating that you are diabetic and in need of
the medical equipment/item checked above and provide the original invoice from an approved vendor
within 10 days of application.
_________________________________________ ___________________
SIGNATURE OF APPLICANT DATE
_________________________________________ ___________________
SIGNATURE OF SPECIAL DIABETES COORDINATOR DATE
Date Received: ________________ By: ____________________
For Office use only:
Approved ____________Denied ____________
Reason: _______________________________________________________________________
Amount: ____________
Referred to: ___________________________________________________________________
