Please download and print these commonly requested forms. If you need additional assistance, please contact member services at
(608) 828-4853 or
(800) 605-4327. We’re happy to send forms by email or the US Postal Service.
Please note that as of Aug. 23, 2016, 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.
CIOX Health's copy fees - Patient UseMedical Record Amendment FormAuthorization for CommunicationAuthorization to Receive Medical Information From Another FacilityAuthorization to Receive Medical Records From Another Facility (Español)Authorization to Release Medical Information From GHC-SCWAuthorization to Release Medical Records from GHC-SCW (Español)Authorization to Release Payment InformationPersonal Representative FormPower of Attorney for Health CarePower of Attorney for FinancesRestriction FormRevocation Form
Authorization for GHC-SCW to Provide Care to Your Minor Child In the Absence of a Parent Medical History Form (Adult – English)Medical History Form (Pediatrics – English)Medical History Form (Adult – Español)Medical History Form (Pediatrics – Español)Consent for Non-Emergency Care & Treatment of Minors to Temporary Caregiver(s)Consent for Non-Emergency Care & Treatment of Minors to Temporary Caregiver(s) (Español)Formulary Exception Request Form
Prescription Drug Claim Form for Direct Member Reimbursement
Patient Request for Health Information Form
Auto Payment Form - Insurance Premiums
Wellness Reimbursement Options and Requirements
Wellness Reimbursement Form - Please use only if you are unable to apply through your GHCMyChart Account.
GHC-SCW Member Appeal Form
GHC-SCW Provider Appeal Form
(608) 828-4853 or
(800) 605-4327, request Member ServicesMon. – Fri., 8 a.m. – 5 p.m.Email Member Services