Frequently Requested Forms 

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.

Release of Information Forms

Medical Record Amendment Form
Authorization for Communication
Authorization to Receive Medical Information From Another Facility
Authorization to Receive Medical Records From Another Facility (Español)
Authorization to Release Medical Information From GHC-SCW
Authorization to Release Medical Records from GHC-SCW (Español)
Authorization to Release Payment Information

Personal Representative Form
Power of Attorney for Health Care
Power of Attorney for Finances
Restriction Form
Revocation Form

Health Care Forms

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

Wellness Reimbursement Forms

Wellness Reimbursement Options and Requirements   

Wellness Reimbursement Form - Please use only if you are unable to apply through your GHCMyChart Account.

Appeal Forms

GHC-SCW Member Appeal Form
GHC-SCW Provider Appeal Form

Connect with Member Services

(608) 828-4853 or (800) 605-4327, request Member Services
Mon. – Fri., 8 a.m. – 5 p.m.
Email Member Services