Forms

Notice of privacy practices (PDF) 84K
WHN’s Notice of Privacy Practices describes how your Protected Health Information (PHI) may be used and/or disclosed by WHN in the course of providing care to you.

Hoosier Healthwise (HH) application (PDF) 68K   |   Instructions for application (PDF) 96K
In order for you to become eligible for Hoosier Healthwise, you must first complete an application. To speed up the approval process, you may print off the attached application and drop off or mail to either Health Center.

Healthy Indiana Plan (HIP) application
The Healthy Indiana Plan (HIP) will provide state-funded health insurance for uninsured Hoosier adults between 18-64 whose household income is between 22%-200% of the Federal Poverty Level.

HIP application - English (PDF) 416K  
HIP application – Spanish (PDF) 732K  

Sliding Fee Scale application (PDF) 48K
In order to become eligible for the WHN ’s Sliding Fee Discount Program, you must first complete a Sliding Fee Scale Application. To speed up the approval process, you may print off the attached application and drop off at or mail to any of our four Health Centers.