At-Large Health Management / Insurance Program Application PacketA 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 FormPlease do not send cover sheet, medical records or supportive documents when faxing to Med Records
Community Supported Agriculture Application and AgreementEvery year, members must provide a new Ho-Chunk Nation CSA application and co-pay to the Health and Wellness Team.
Fitness Membership Reimbursement Program ApplicationApplication for Fitness Membership Reiembursement for Ho-Chunk Nation enrolled tribal members and family members not to exclude descendants under the age of 18.
Fitness Membership Reimbursement Program PolicyIt is the policy of the Health and Wellness Team to offer a 6 month reimbursement program for fitness memberships to Ho-Chunk enrolled Tribal members to encourage increasing physical activity.
Food Distribution ApplicationApplication for the Food Distribution Program on Indian Reservations (FDPIR)
Patient Complaint FormIf 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.
Pharmacy Credit Card Authorization FormPlease completely fill out the credit card authorization form and mail, fax, or drop off at either pharmacy location. Payment is for co-pays, co-insurance, non-covered services, and deductables that are due at the time of dispensing medications.
Pharmacy Prescription Medication Transfer FormUse this form to transfer your current prescription medications to the Ho-Chunk Nation's Pharmacy.
Purchased / Referred Care ApplicationThe Purchased / Referred Care Application and a Medical Release form. The application requires a yearly update and also an update whenever reported information changes.
Unaccompanied Minor FormThe Unaccompanied Minor Form
WIAA Sports Physical FormSports Physical Form