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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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GHCMYCHART LOG-IN

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