trust us for life

serious medicine
extraordinary care

Caring for the Growing Needs of Our Community.

Patient Forms

New Patient Health Questionnaire

Patient Forms
Patient Forms

Sliding Fee Scale Application

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 one of our five Health Centers. For your security, please do not submit SFS documents through the website. Fill out and return to office. Call your health center to schedule an appointment with a Navigator to complete any of these forms.

Patient Forms
Patient Forms

Notice of Privacy Practices

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 (Medicaid) Application

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.

Patient Forms
Patient Forms

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.

Request a Call Back

We can call you back

Pellen tesque in ipsum id orci porta dapibus curabitur non nulla sit amet nisl tempus convallis quis ac lectus.




Emergency Call

In case of urgent, feel free to ask questions.