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GHC-SCW Forms

Important Forms for Members

Authorization For GHC-SCW to Provide Care to Your Minor Child In the Absence of a Parent
Authorization for Verbal Communication
Authorization to Release Medical Records From GHC-SCW
Autorización Para Que GHC-SCW Pueda Divulgar Información Médica Protegida
Authorization to Receive Medical Records From Another Facility
Autorización Para Recibir Información Médica DeOtro Centro
Authorization to Release Payment Information
Consent for Adult Access to a Minor’s (0-17) GHCMyChart℠
Consentimiento para el acceso de un adulto al expediente de GHCMyChart℠ de un menor (0-17)
Consent for Minor Self-Access to GHCMyChart℠
Consentimiento para acceso del menor al expediente de GHCMyChart℠
Patient Request for Health Information Form​
Power of Attorney for Finances​
Power of Attorney for Health Care
Request for an Accounting of Disclosures
Request for Confidential Communications
Request for Medical Record Amendment
Restriction Request for Protected Health Information
​Revocation of Prior Authorization
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