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Patient Name: DOB: Address: Home Phone: Email: Cell Phone: Physician/Pediatrician/PCP Referral: Lactation/Speech Referral: Preferred Pharmacy: Address: Responsible Parties Information: Name: DOB:
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How to Fill Out American Indian or Alaska:

01
Start by obtaining the necessary application form for American Indian or Alaska Native status. This form can typically be found online or obtained from your local tribal office or the Bureau of Indian Affairs.
02
Carefully read the instructions provided with the application form. Make sure you understand the requirements and any supporting documents that may be needed.
03
Begin filling out the application form by providing your personal information such as your full name, date of birth, and contact details. Be sure to provide accurate and up-to-date information.
04
If you are applying on behalf of a child, provide their information as well, including their full name, date of birth, and any tribal affiliation they may have.
05
Indicate whether you are applying for American Indian or Alaska Native status. If you have a specific tribal affiliation, make sure to mention it as well.
06
Provide any additional information or documentation required, such as proof of tribal enrollment, birth certificates, or other supporting documents. Follow the instructions carefully to ensure you meet all the requirements.
07
Check the completed application form thoroughly for any errors or omissions. Make sure your handwriting is legible and easy to read.
08
Sign and date the form where required. If you are applying on behalf of a child, the parent or legal guardian should sign.
09
Make copies of the completed application form and any supporting documents for your records.
10
Submit the application form, along with any required documents, to the designated address or office as instructed.

Who Needs American Indian or Alaska Native Status:

01
Individuals who identify as American Indian or Alaska Native and want to establish official recognition of their heritage may need American Indian or Alaska Native (AI/AN) status.
02
People who wish to access benefits, services, or programs that are specifically available to American Indian or Alaska Native individuals may require AI/AN status. These benefits can include healthcare, education, housing assistance, scholarships, and cultural preservation programs.
03
Some employers, universities, or organizations may require proof of AI/AN status for eligibility purposes. This can be relevant for employment opportunities, college admissions, or participation in certain cultural or educational events.
04
Individuals who are part of a federally recognized tribe may need to fill out the American Indian or Alaska Native application form to establish their tribal affiliation officially.
05
It is important to note that each tribe may have its own specific enrollment requirements and processes. Therefore, it is recommended to consult with your tribal office or the Bureau of Indian Affairs to determine the specific needs and eligibility criteria for obtaining AI/AN status.
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American Indian or Alaska Native refers to a person having origins in any of the original peoples of North and South America (including Central America) and who maintains cultural identification through tribal affiliation or community recognition.
Individuals who are American Indian or Alaska Native and want to report their tribal affiliation or community recognition may choose to file American Indian or Alaska Native.
To fill out American Indian or Alaska Native information, individuals need to provide details about their tribal affiliation or community recognition on the appropriate tax forms.
The purpose of reporting American Indian or Alaska Native information is to provide accurate data on the diversity of the population and to support programs that benefit Native American communities.
Individuals need to report their tribal affiliation or community recognition, which helps in identifying their cultural identity and heritage.
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