Fillable Chickasaw!Nation!Refill!Center! Native!&!Non-Native!Spouse!Prescription!Program! Enrollment!Form! (The Chickasaw Nation)

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Chickasaw!Nation!Refill!Center! Native!&!Non-Native!Spouse!Prescription!Program! Enrollment!Form! (The Chickasaw Nation)

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Chickasaw!Nation!Refill!Center!
Native!&!Non-Native!Spouse!Prescription!Program!
Enrollment!Form!
!Female! Marital!Status:! !!S!! !!M! !D! !!W!
County:!
!State:!
!ZIP:!
Date!of!birth:!
!!!!Age:!
Cell!phone:!
Chickasaw!citizen:!!!Yes!
!No!
Name:!
Gender:!!!!!!!!!!!!Male!!!!!!
Current!Mailing!Address:!
City:!
Social!Security!number:!
Home!phone:!!
Email!address:!
Medication!allergies:!!
Eligible!participants:!
• Native!Americans!and!spouses!with!active!private!or!Medicare!Part!D!prescription!coverage
(includes!federally!recognized !tribes!only ).
• For!uninsured!Chickasaw!citizens!less!than!19!years!of!age!living!outside!of!the!Chickasaw!Nation!boundaries,
please!contact!the!Chickasaw!N ation !Refill!Cen ter!fo r!elig ib ility!r eq u ire m e n ts!for !pr es crip tio n !ass ista n ce .
All!participants!must!submit!a!completed!application!and!documentation!listed!below:!
Completed!application!!!!!(each!participant!must!submit!a!separate!application)!
Copy!of!CDIB!!!!!(all!participants)!
Copy!of!tribal!citizenship!card!!!!!(all!participants)!
Copy!of!prescription!insurance!card,!front!and!ba ck! !!!!(all!pa rticipants)!
Copy!of!marriage!license!!!!!!
Signed!Acknowledgement!of!Receipt!of!Notice!of!Privacy!Practices!form!!!!!(all!participants)!
Approved!medications!will!be!provided!at!no!cost!to!the!patient.!
Under!penalty!of!law,!I!hereby!understand!and !agre e!to!all!Conditions!of!Participation!and!guidelines!of!the!program.!
Applicant’s!signature!or!legal!guardian! !!!!!!!!!!!!!!Date!
Please!mail!or!fax!completed!forms!and!prescriptions!to:!
Chickasaw!Nation!Refill!Center! Local:! !!!!!!580-421-8725!
933!N.!Country!Club!Road!!! Toll!Free:!!!!!855-478-8725!
Ada,!OK!74820!! ! Fax:! !!!!!!580-421-8701!
Chickasaw Nation Refill Center
Native & Non-Native Spouse Prescription Program
933 N. Country Club Road
Ada, OK 74820
CNRefillCenter@Chickasaw.net
Form no. 02905 TCH-RC Rev. 4/2016
Conditions!of!Participation!
This!benefit!is!available!to!Native!Americans!and!spouses!with!active!prescription!insurance!and!the!following!
documentation:!
1. Proof!of!Native!American!heritage!through!a!federally!recognized!tribe!via!Certificate!of!Degree!of!Indian!Blood!or
Certificate!of!Degree!of!Alaska!Native!Blood!(both!abbreviated!CDIB)
2. A!tribal!citizenship!card.!
• The!“Acknowledgement!of!Receipt!of!Notice!of!Privacy!Practices”!portion!of!the!application!must!be!completed,!signed
and!returned!with!all!applications.
• In!the!event!that!an!applicant’s!legal!name!does!not!match!the!name!printed!on!the!applicant’s! CDIB,!the!applicant must!
provide!a!copy!of!a!marriage!license,!divorce!decree,!or!other!legal!document!in!reference!to!any!name!change!or
discrepancy.
• All!prescriptions!are!subject!to!the!policies,!terms!and!conditions!of!individual!insurance!providers.!Prescription
insurance!plans!and!individual!prescriptions!may!be!subject!for!review!in!cases!of!non-payment!to!the!Chickasaw
Nation!Refill!Center.
• Some!medications!may!be!subject!to!certain!limitations!and!conditions.!Please!consult!your!insurance!plan!provider!to
verify!medication!exclusions!and!limitations!relating!to!the!plan.
• Written,!phoned-in,!faxed!or!electronic!prescriptions!from!your!provider! will!be! accepted.!Transferred!prescriptions
from!other!pharmacies!are!not!accepted.
• For!patients!living!outside!of!Oklahoma,!all!prescriptions!must!be!written!by!a!doctor!of!medicine!(MD)!or!doctor!of
osteopathic!medicine!(DO).!We!cannot!accept!prescriptions!authorized!by!physician!assistants!and!nurse!practitioners
who!are! not!licensed!in!the!state!of!Oklahoma.
• All!prescriptions!will!be!subject!to!both!federal!and!Oklahoma!pharmacy!laws!and!regulations.
• All!controlled!medication!prescriptions!will!be!subject!for!review!pursuant!to!Oklahoma!statutes!and!the!Chickasaw
Nation!Refill!Center!policies.
• Controlled!substance!prescriptions!cannot!be!mailed!and!must!be!dispensed/picked-up!at!the!Chickasaw!Nation!Refill
Center.!A!valid!form!of!identification!is!required!for!both!the!patient!receiving!the!medication!and!the!individual/agent
picking!up!the!medication!pursuant!to!Oklahoma!statutes.
• Compounded!substances,!investigational!drugs!and!over-the-counter!(OTC)!drugs!are!not!included!in!this!program.!
Chickasaw Nation Refill Center
Native & Non-Native Spouse Program
933 N. Country Club Road
Ada, OK 74820
CNRefillCenter@Chickasaw.net
Form no. 02905 TCH-RC Rev. 4/2016
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ChickasawNationRefillCenter Native&Non-NativeSpousePrescriptionProgram EnrollmentForm (The Chickasaw Nation)

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Completed 31 January 2021

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