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 reccords or supportive documents when faxing to Med Records
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.
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.