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Frequently Requested Forms

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Frequently Requested Forms
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Please download and print these commonly requested forms.

Some are even available to fill out online. We’re also happy to send forms by email or the US Postal Service.

  • If you need additional assistance, please contact Member Services at (608) 828-4853 or (800) 605-4327.
  • Please note that now 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.
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Release of Information Forms
CIOX Health's Copy Fees
Medical Record Amendment Form
Authorization for Verbal Communication
Authorization to Receive Medical Information From Another Facility
Authorization to Release Medical Information From GHC-SCW
Authorization to Release Payment Information
Power of Attorney for Health Care
Restriction Form
Revocation Form
Health Care Forms
Authorization for GHC-SCW to Provide Care to Your Minor Child in the Absence of a Parent
Medical History Form (Adult)
Medical History Form (Pediatrics)
Consent for Non-Emergency Care & Treatment of Minors to Temporary Caregiver(s)
Formulary Exception Request Form
Web
Prescription Drug Claim Form for Direct Member Reimbursement
Legal S​ex De​signation Change form
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
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

Electronic Health Information (EHI) Export

The 21st Century Cures Act Final Rule requires providers to export all EHI that is stored for a single patient whose EHI is in the system (EPIC) upon request by the patient. The export is a machine-readable format file and contains all health information that a patient already has the right to access through the release of information process. This file is easily understood and processed by computers, not humans and would require outside tools and software to interpret.

If you would like more information about the EHI export, please contact the HIM and Privacy Manager via email privacy@ghcscw.com or (608) 662-4899.