Tribal vaccine promotion: Get your shot(s), receive $200, help protect others
Purpose: To increase vaccinated Tribal members and staff, CTSI is providing a $200 cash payment to Tribal members (all ages), CTSI staff and CTSI entities staff (IAD,
STGC, STBC and Tenas Illahee) to complete their COVID-19 vaccine series.
COVID-19 Vaccine - Must complete
vaccine series to qualify for incentive
by Dec. 15, 2021.
Qualifying series
• Moderna – 2 shots
• Pfizer – 2 shots
• Johnson & Johnson – 1 shot
Who is eligible
Enrolled Siletz Tribal members – all
ages – living anywhere
• Ages 14 and older – check is pay-
able to individual Tribal member
• Ages 13 and under – check is pay-
able to PARENT of Tribal minor
or guardian (must provide proof
of guardianship and W-9)
Vaccine Promotion Application for Siletz Tribal Members
(14 years of age and older)
Name: _________________________________ DOB: ____________ Roll # _______
Mailing Address: _____________________________________________________
____________________________________________ Phone # ________________
Vaccine Location: ____________________________________ (Siletz Clinic, Fred
Meyer, Salem Armory, etc.)
Read carefully to ensure you’re sending required documentation:
_______ I received my vaccine @ Siletz Clinic – Send application only
_______ I received my vaccine in Oregon* – Send application only
_______ I received my vaccine outside of Oregon – Send application and copy of
vaccine record
Signature: __________________________________________ Date: ____________
*If site does not report to Oregon Alert, you’ll be contacted to provide a copy of your
vaccine card.
**If your Social Security number is not on file with CTSI, we will need a copy of it
or W-9.
***More than 1 family member: Provide above information on separate sheet of paper
and send.
Vaccine Promotion Application for Siletz Tribal Members
(13 years of age and younger)
Name: _________________________________ DOB: ____________ Roll # _______
Legal Guardian Name: __________________________________________________
Mailing Address: _____________________________________________________
_______________________________________________ Phone # _____________
Vaccine Location: ______________________________________ (Siletz Clinic, Fred
Meyer, Salem Armory, etc.)
Read carefully to ensure you’re sending required documentation:
_______ I received my vaccine @ Siletz Clinic – Send application ONLY
_______ I received my vaccine in Oregon* – Send application ONLY
_______ I received my vaccine outside of Oregon – Send application AND copy of
vaccine record
Proof of Guardianship
_______ I am the legal parent and enrolled Siletz Tribal member – No additional
information required.
_______ I am the legal parent and NOT an enrolled Tribal member – Send W-9
_______ I am the legal guardian – Send proof of guardianship and W-9
I attest the minor child resides with me and I am the legal guardian. I understand
that supplying false, incomplete or inaccurate information is punishable under federal,
state or Tribal laws.
Signature: ____________________________________________ Date: ____________
*If site does not report to Oregon Alert, you’ll be contacted to provide a copy of your
vaccine card.
**More than 1 family member: Provide above information on separate sheet of paper
and send.
Mail or email your application
Mail to: Siletz Community Health Clinic, Attn. Vaccine, P.O. Box 320 Siletz, OR 97380
Email to: Covidline@ctsi.nsn.us
10 •
Siletz News
•
October 2021
Staff
• CTSI, IAD, STGC, STBC and
Tenas Illahee, including full/part
time and temporary employees
• Currently employed by CTSI/
entities at time of application
and payment
How to apply
Complete application and provide
requested documentation
• Vaccine Program staff will verify
vaccine series in Oregon Alert
when vaccine card not submitted.
Application and W-9 are available
on website – ctsi.nsn.us
Payments
3 payment cycles available:
• Sept. 8, 2021 – application/docu-
mentation received Aug. 30
• Nov. 3, 2021 – application/docu-
mentation received Oct. 22
• Dec. 29, 2021 – application/
documentation received Dec. 15
Program information
Tribal members who are also
employees are only eligible for one
promotion payment of $200
Payment is not reportable income
Vaccine promotion ends Dec. 15,
2021 – must apply no later than
Dec. 15, 2021.
Siletz Community Health Clinic
Purchased/Referred Care – Newly Available Service
PRC Funding for Specialty Surgery
Dental Services and Funding
PRC-eligible patients living within
Tribal Council approved funding for
medically necessary surgeries that are not 40 miles of the Siletz Clinic or an IHS
currently approved services. To qualify, facility are now eligible to obtain services
you must be an enrolled Siletz Tribal at an outside dental facility. You may also
member AND PRC-eligible. Eligible be eligible for implant(s) as the result of
reduced access to dental care from den-
surgeries include:
tal office closures or reduced capacities.
• Excess eyelid skin removal
Implant requests go through Gatekeepers
• Breast reduction
to determine eligibility.
• Excess abdominal skin removal
Contact PRC for additional informa-
PRC will process requests through
Gatekeepers; funding is limited and
will be first-come, first-served. The
established medically necessary criteria
are consistent with CMS and insurance
guidelines. Requests deemed as cosmetic
will not qualify.
tion at 541-444-1236.
Out-of-area Tribal members are eligible
for an additional benefit of $3,000 for dental
services, which must be received by Dec. 31,
2021. Funding is limited.
Contact the COVID Team for addi-
tional details at 541-444-9607.