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.
Release of Information Forms
CIOX Health's Copy Fees
Medical Record Amendment Form
Authorization to Release Payment Information
Power of Attorney for Health Care
Health Care Forms
Authorization for GHC-SCW to Provide Care to Your Minor Child in the Absence of a Parent
Formulary Exception Request Form
Prescription Drug Claim Form for Direct Member Reimbursement
Legal Sex Designation Change form
Ages and Stages Child Check-Up Questionnaire Forms
Health Insurance Forms
MyChart Payment & Auto Payment Information - Insurance Premiums
Patient Request for Health Information Form
Subscriber Reimbursement Medical Claim Form