Child Patient Registration

LITTLE TRAVERSE BAY BANDS OF ODAWA INDIANS

HEALTH DEPARTMENT

1260 AJIJAAK AVE

PETOSKEY, MI 49770

P: 231-242-1700

CHILD PATIENT REGISTRATION

REQUIRED DOCUMENTATION

Use this list to ensure you provide the LTBB Health Department with all required documentation. Failure to do so will result in delay of your care.

Document Checklist:

Tribal Identification Card from a Federally recognized Tribe (State Recognized Tribes are not eligible) OR Proof of descendency from a Federally Recognized Tribe

Birth Certificate

Social Security Card

Driver's License OR State Identification card (must include a photo, name, address, and date of birth)

Two (2) proofs of physical address (no RV parks or PO boxes accepted)

All active insurance cards (medical, dental, vision)

Completed Registration Packet

Any legal documents relevant to patient care (legal guardianship, adoption, foster care, power of attorney related to medical services)

CHILD PATIENT REGISTRATION

For the Little Traverse Bay Bands of Odawa Indians (LTBB) to provide efficient health services while following federal regulations, you must complete this form and return it to our Central Registration. If completed, the information provided will assist the LTBB Health Department in the best course of healthcare and available resources.

Full legal name: *

Preferred name/alias:

Date of Birth: *

Social Security Number: *

Sex on birth cerificate: *

Marital status:

City and State of birth: *

Physical Address: *

Mailing Address (if different from physical):

City, State, Zip code: *

State *

Home Phone: *

Cell Phone:

Work Phone:

Email:

Are you a descendant or citizen of a Federally Recognized Tribe: *

Citizen

Descendant

Tribal affiliation: *

Enrollment number OR list descendancy: *