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Frequently Requested Forms 

Please download and print these commonly requested forms. If you need additional assistance, please contact member services at (608) 828-4853 or (800) 605-4327. We’re happy to send forms by email or the US Postal Service.

Please note that as of Aug. 23, 2016, our Release of Information vendor CIOX, requires payment for medical records. If you have questions, please call CIOX Health toll-free at (800) 367-1500.

Release of Information Forms

CIOX Health's copy fees - Patient Use
Medical Record Amendment Form
Authorization for Verbal Communication​​​​​​

Authorization for Verbal Communication - Espa​ñol
Authorization to Receive Medical Information From Another Facility
Authorization to Receive Medical Information From Another Facility - Español
Authorization to Release Medical Information From GHC-SCW
Authorization to Release Medical Information From GHC-SCW - Español
Authorization to Release Payment Information

Power of Attorney for Health Care​​
Power of Attorney for Finances
Restriction Form
Revocation Form

Health Care Forms

Authorization for GHC-SCW to Provide Care to Your Minor Child in the Absence of a Parent
Authorization for GHC-SCW to Provide Care to Your Minor Child in the Absence of a Parent​ - Espa​ñol
Medical History Form (Adult – English)

Medical History Form (Pediatrics – English)
Medical History Form (Adult – Español)
Medical History Form (Pediatrics – Español)
Consent for Non-Emergency Care & Treatment of Minors to Temporary Caregiver(s)
Consent for Non-Emergency Care & Treatment of Minors to Temporary Caregiver(s) - Español
Formulary Exception Request Form
Prescription Drug Claim Form for Direct Member Reimbursement

Ages and Stages Child Check-Up​​ Questionnaire Forms​

Nine Months
Eighteen Months
Twenty-Four Months
Thirty-Six Mon​ths​​

​​Health Insurance Forms

Billing Information Form - English
Billing Information Form - Españ​ol
Billing Information Form - kwv tij hmoob​​​​
MyChart Payment & Auto Paym​ent Information - Insurance Premiums
Patient Request for Health Information Form
Subscriber Reimbursement  Medical Claim Form

Appeal Forms

GHC-SCW Member Appeal Form
GHC-SCW Provider Appeal Form

Connect with Member Services

(608) 828-4853 or (800) 605-4327, request Member Services
Mon. – Fri., 8 a.m. – 5 p.m.
Ema​il Member Services