Emergency 24/7 Call 911   Clinic Hours: 8AM - 4:30PM | Mon - Fri
Pharmacy Hours: 8AM-5PM
Black River Falls Pharmacy closed 12:30PM - 1:30 PM for lunch

Department of Health

The Ho-Chunk Nation | Wisconsin

Downloadable Forms

At-Large Health Management / Insurance Program Application Packet

A blank At-Large Health Management/Insurance Program (ALHM/IP) application and a release of information form to be completed and returned.

At-Large Health Management Referral Form

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

Authorization For Use or Disclosure of Health Information Form (HHCN PR810)

Food Distribution Application

Application for the Food Distribution Program on Indian Reservations (FDPIR)

Patient Complaint Form

If you have a concern about the services you received through the Ho-Chunk Nation Health Care facilities, please complete this form and return to Quality Improvement Director.

Purchased / Referred Care Application

The Purchased / Referred Care Application and a Medical Release form. The application requires a yearly update and also an update whenever reported information changes.