Downloadable Forms

At-Large Health Management Program Application Packet

A blank At-Large Health Management Program (ALHMP)

At-Large Health Management Program Referral Form

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

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

Brockway PFAS Treatment Application

Ho-Chunk Nation Residential Water Treatment Equipment Installation Program

Fitness Membership Reimbursement Program Policy

It 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 Application

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

Online Patient Feedback Form | Download / Print Patient Feedback Form

If you have feedback about the services you received through the Ho-Chunk Nation Health Care facilities. Fill out the online form or download / print the form and return to Quality Improvement Director.

Pharmacy Credit Card Authorization Form

Please 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 Form

Use this form to transfer your current prescription medications to the Ho-Chunk Nation's Pharmacy

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

Release of Information Form (ROI)

A document that authorizes the disclosure of a person's confidential information to a specified party

Unaccompanied Minor Parental Consent Form

The Unaccompanied Minor Parental Consent Form

Water Sewer Service Request Form

Application and payment agreement form requesting public water supply/sewer use service from the Department of Health

WIAA Sports Physical Form

Sports Physical Form