APPLICATION FOR DIABETIC EYEWEAR ASSISTANCE by Kaw Nation | Dec 15, 2023 | Social Services Applications Today's Date *First Name *Last Name *Maiden NameStreet Address *Apartment, suite, etcCity *State *Enter State Abbreviation0 / 2Zip Code *Phone Number *Date of Birth *Kaw Roll Number *Currently Employed? *YesNoIf not, enter last date of employment.Last 4 Digits of Social Security Number *Number in Family *Diabetic? *YesNoAre you a patient at the Kanza Clinic? *SelectYesNoIf so, do you attend the Diabetic Program? *SelectYesNoList Medicare, vision/dental insurance, state assistance, etc.Please attach documentation showing that you are a diabetic patient from your doctor/service provider. *Choose FileNo file chosenDelete uploaded fileType of assistance requested: Please check all that apply./ Eyeglass Wear - ($400 approved every two years)TRB SS #6620Acknowledgement *Yes, I agree that amounts exceeding the approved amount will be the responsibility of the applicant. All applications must be approved BEFORE MAKING YOUR APPOINTMENT. The Kaw Nation cannot make payments on previous balances prior to the application date.Signature of applicant – Parent/Guardian must sign application for minors. By signing, you certify that you are an enrolled citizen of the Kaw Nation. Dual enrollment with another tribe is not allowed. If evidence of dual enrollment is found, this application will be void and services will be denied. If evidence of dual enrollment is found after services are received, legal action may be taken to recover any benefits awarded. *Start signing your signature hereYour browser does not support e-Signature field.Submit Application
