​Forms to Submit Prior Authorization Requests

Failure to obtain Prior Authorization may result in GHC-SCW not providing coverage for the service. The prior authorization lists may differ depending on health plan type.

Which Prior Authorization Form To Use?

Medical Services Prior Authorization Forms

Pharmacy and other Medication Requests ​

Behavioral Health and Substance Use Disorder Treatment Forms

Please fax completed forms to (608) 831-6099.​ Please Upload your Pdfs Here: (Save each form individually then select all PDf's to upload at one time​)​

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​ Questions

  • Medication Related Questions & Requests: Contact the GHC-SCW Pharmacy department at (608) 828-4811.
  • Coverage and Prior Authorization Requirements: Contact Member Services, Mon. - Fri., 8 a.m. - 5 p.m. at (608) 828-4853 or toll free at 800-605-4327, and ask to speak with Member Services.
  • Prior Authorization Status: Contact GHC-SCW Care Management team by phone (608) 257-5294, or by fax (608) 831-6099.