We apologize for the inconvenience.
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 August, 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.
Authorization for Verbal Communication - EspañolAuthorization to Receive Medical Information From Another FacilityAuthorization to Receive Medical Information From Another Facility - EspañolAuthorization to Release Medical Information From GHC-SCWAuthorization to Release Medical Information From GHC-SCW - EspañolAuthorization to Release Payment InformationPower of Attorney for Health CarePower of Attorney for FinancesRestriction FormRevocation Form
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) - EspañolFormulary Exception Request Form
Prescription Drug Claim Form for Direct Member Reimbursement
Billing Information Form - EnglishBilling Information Form - EspañolBilling Information Form - kwv tij hmoob
MyChart Payment & Auto Payment Information - Insurance PremiumsPatient Request for Health Information Form
Subscriber Reimbursement Medical Claim Form
GHC-SCW Member Appeal Form
GHC-SCW Provider Appeal Form
(608) 828-4853 or
(800) 605-4327 and request Member Services.Monday – Friday, 8 a.m. – 5 p.m.Email Member Services