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.
Family Fitness Membership Application and AgreementFitness membership application and terms of agreement. Every 6 months members must provide a new Ho-Chunk Nation
Fitness Membership application to the Health and Wellness staff.
Fitness Membership / Community Supported Agriculture PolicyIt is the policy of the Health and Wellness Team to offer 6 month fitness memberships OR Community Supported Agriculture (CSA) to
Ho-Chunk Nation enrolled tribal members and family members not to exclude descendants.
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.