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Department of Health

The Ho-Chunk Nation | Wisconsin

At-Large Health Management / Insurance Program

Approved applicants are required to notify the At-Large Management / Insurance Program (ALHM/IP) of any changes of personal information made throughout the year. Failure to notify the ALHM/IP Program of any changes will result in the termination of your benefits and any bills incurred after the termination date will be your responsibility to pay. You are required to update your application yearly or your benefits will terminate.

ALHM/IP is not intended to pay old bills or non-medical needs. It is not an entitlement program and is to be considered as a payor of last resort. Applicants are required to apply for alternate resources(s) or their application will be denied. A letter of decision must be received in this office, before your application will be considered.

Whether your application is approved or denied, you will receive notice in the mail. If your application is approved, you are required to call and preauthorize your appointments. If no authorization was given, your claims will be denied and you will be responsible for payment of unauthorized services.

Return your completed application and required information to:

Ho-Chunk Nation At-Large Health
Management / Insurance Program

P.O. Box 636
N6520 Lumberjack Guy Road
Black River Falls, WI 54615

If there are any questions or concerns, please do not hesitate to call 715-284-9851 Ext. 5315

NOTE: IF REQUIRED INFORMATION IS APPLICABLE BUT NOT INCLUDED, YOU WILL BE NOTIFIED BY MAIL AND YOUR APPLICATION WILL BE ON HOLD 30 DAYS; IF AFTER 30 DAYS THIS INFORMATION IS NOT RECEIVED YOUR APPLICATION WILL BE DENIED. IF AFTER THIRTY (30) DAYS OF SUBMITTING YOUR APPLICATION YOU HAVE NOT RECEIVED NOTICE TO THE STATUS OF YOUR APPLICATION PLEASE CONTACT THE ALHM/IP PROGRAM AT 715-284-9851 EXT 5058. IF AT ANY TIME THE INFORMATION YOU SUBMIT IS FOUND TO BE UNTRUE, YOUR BENEFITS WILL TERMINATE AND ANY BILLS INCURRED AFTER THE TERMINATION DATE WILL BE YOUR RESPONSIBILITY TO PAY.

The blank At-Large Health Management / Insurance Program (ALHM/IP) application includes a release of information form to be completed and returned. To avoid any delays in the processing of your application a checklist is enclosed. Be sure to list all household income and members.

DOWNLOAD THE APPLICATION

_____________Other Forms_____________

At-Large Health Management Referral Form

Please do not send cover sheet, medical reccords or supportive documents when faxing to Med Records