PRC Online Application

The Purchased/Referred Care (PRC) application and Authorization for Release of
information must be completed and returned. Be sure to include all members of your immediate family under the age of 18 years old.

The Purchased/Referred Care Program requires an Annual Update and must be notified when reported information changes. If upon review of your application you are found to be eligible, application will be approved and you will be notified by mail.

Applicants must submit the items listed below (1-5) with the application:
1) Copies of all household income;
2) Copies of medical, dental and prescription insurance cards;
3) If you don’t have insurance then you are required to meet with a benefit specialist;
4) Copies of enrollment verification (new applicants);
5) Physical address verification (i.e. Drivers License, Wisconsin ID, utility bill, or lease agreement).

*NOTE: IF ANY OF THE ABOVE INFORMATION IS NOT INCLUDED, A LETTER WILL BE SENT INFORMING YOU OF ADDITIONAL INFORMATION NEEDED; YOUR APPLICATION WILL NOT BE APPROVED UNTIL ALL REQUIRED INFORMATION IS RECEIVED.

Purchased/Referred Care is the "payer of last resort" and, under our contract, is required to verify eligibility for alternate resources of medical and dental coverage. The above information is used to determine whether you are eligible for other coverage and/or programs.

Ho-Chunk Nation
Purchased/Referred Care
P.O. Box 636
N6520 Lumber Jack Guy Rd
Black River Falls, WI 54615
Email: PRC@Ho-Chunk.com
Phone: (715) 284-9851
Fax: (715) 284-0100

PLEASE RETURN YOUR APPLICATION WITHIN 30 DAYS OR YOU WILL NO LONGER BE CONSIDERED FOR COVERAGE.

FIRST NAMEMIDDLE NAME (COMPLETE)LAST NAME

NUMBER AND STREET

Street Address Line 2

CITYSTATE

ZIP CODE

FIRST NAMEMIDDLE NAME (COMPLETE)LAST NAME

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO NOTIFY THE PURCHASED REFERRED CARE PROGRAM OF ANY CHANGE IN THE ABOVE INFORMATION WITHIN 30 DAYS OR MY PRC BENEFITS MAY BE TERMED OR DENIED.

APPLICATION MUST BE UPDATED ONCE PER YEAR
ALLOW 30 DAYS FOR PROCESSING

I, YOUR NAME authorize the Purchased Referred Care (PRC) Program Staff and its Providers to receive any information related to health care and financing for the individuals listed below:

From any person, health care provider, hospital, other health care facility, governmental agency, corporation or other organization.

Information to be released includes applications, records, reports, assessments, evaluations, and other related information for the purpose of further medical care / insurance application/payment of insurance claims / disability determination / legal investigation / public program eligibility or other: PLEASE SPECIFY

I understand this Authorization is subject to revocation by me at any time. I also understand that a photocopy of this Authorization has the same effect as the original.

I am the Individual named/Parent/Guardian/Conservator for which Authorization is given.

This Authorization for Release of Information expires one (1) year from the date on which it is signed.

MAILCELL PHONEE-MAIL

VETERANS BENEFITS / SOCIAL SECURITY / SUPPLEMENTAL SECURITY INCOME

UNEMPLOYMENT / DISABILITY / WORKMANS COMPENSATION / PER CAPITA

TOTAL MONTHLY INCOME FROM ALL SOURCES

AUTHORIZATION FOR RELEASE OF INFORMATION