Medical Emergency Assistance Form 002_Revised March 2019
Medical Assistance Program
This program is for Delaware enrolled citizens that need assistance with purchasing durable medical
equipment and/or prescriptions that is not covered by Medicare, private insurance or Indian Health
Services. This program will be available to tribal citizens once a year up to $1,000.
This program WILL NOT pay for medical bills
*Please check the box that applies to you.
Tribal Elder 60 years and older
➢ Applicant must be considered disabled, physically disabled or mentally disabled by a physician.
Or have a life threatening illness.
Tribal Citizen under 60 with medical disability
➢ Applicant must be considered disabled, physically disabled or mentally disabled by a physician.
Or have a life threatening illness.
REQUIRED DOCUMENTS The following documents must be submitted with this application. If you
fail to submit these documents, your application will be placed on pending status.
✓ Copy of CDIB card
✓ Copy of prescription from the physician.
✓ Statement from the physician, clinic or hospital explaining your injury and/or disability.
✓ Proof of income
✓ Proof of insurance or Medicare
ATTENTION: Applicants must have denial statements from insurance, Indian Health Services or
other medical facility in order to receive services. Denial must state that prescribed medical
equipment or prescriptions are not covered by insurance or Indian Health Services.
DEADLINE
No deadline.
SERVICE AREA
Nationwide
