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Capital Clinic closed from 1/16 to 1/20 and holiday hours in effect for all clinics 1/18. Información en español abajo. View more information here

Capitol Clinic Closed 1/16 to 1/20 and Martin Luther King Jr. Day Clinic Hours

Safety is always our highest priority for both staff and members. At the suggestion of local law enforcement, we will be minimizing staffing on the isthmus by moving Capitol Clinic Urgent Care and Clinic Staff to our Hatchery Hill clinic location from Saturday 1/16 through Wednesday 1/20. All other Capitol Clinic services will be moved to other sites or to virtual visits during this time.
La seguridad es siempre nuestra máxima prioridad tanto para nuestro personal como para nuestros miembros. A sugerencia de las autoridades policiales locales, minimizaremos la dotación de personal localizada en el istmo de la ciudad, trasladando a nuestro personal de atención de urgencias y de la clínica del Capitolio a nuestra clínica de Hatchery Hill, a partir del sábado 16 de enero hasta el miércoles 20 de enero. Todos los demás servicios de la clínica del Capitolio se trasferirán a otros sitios o a visitas virtuales durante este espacio de tiempo. Por favor si tiene cualquier pregunta puede dirigirla a la administración o visite nuestro sitio web para obtener más información acerca de nuestros próximos horarios en ghcscw.com
We will also be implement holiday hours on 1/18/21 in observance of Martin Luther King Jr. Day at all our GHC-SCW owned clinics which include:
Capitol Clinic
Capitol-Regent Behavioral Health Clinic
DeForest Clinic
East Clinic
Hatchery Hill Clinic
Madison College Community Clinic
Physical Therapy at Princeton Club West
Sauk Trails Clinic
GHC-SCW Holiday Schedule
Martin Luther King Jr. Day
1/18/21
GHC-SCW Clinics and Administrative Offices

Closed
GHC-SCW Urgent Care Clinic at Hatchery Hill
Open 9 a.m. - 10 p.m.
Hatchery Hill Pharmacy 9 a.m. - 5 p.m.

Other GHC-SCW Pharmacies
Closed

Horario de las clínicas de GHC-SCW durante días festivos
Group Health Cooperative of South Central Wisconsin (GHC-SCW) implementará un horario especial para El Día de Martin Luther King Jr. en las siguientes clínicas:
Capitol Clinic
Capitol-Regent Behavioral Health Clinic
DeForest Clinic
East Clinic
Hatchery Hill Clinic
Madison College Community Clinic
Physical Therapy at Princeton Club West
Sauk Trails Clinic
Horario especial de GHC-SCW
El Día de Martin Luther King Jr.

1/18/21
Las clínicas y oficinas administrativas de GHC-SCW estarán cerradas
La clinica GHC-SCW de Cuidado Urgente de Hatchery Hill Clinic estará abierta de 9 a.m. a 10 p.m.
La farmacia del Hatchery Hill estará abierta de 9 a.m. a 5 p.m.
Otras farmacias de GHC-SCW están cerradas

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

CIOX Health's copy fees - Patient Use
Medical Record Amendment Form
Authorization for Verbal Communication

Authorization for Verbal Communication - Español
Authorization to Receive Medical Information From Another Facility
Authorization to Receive Medical Information From Another Facility - Español
Authorization to Release Medical Information From GHC-SCW
Authorization to Release Medical Information From GHC-SCW - Español
Authorization to Release Payment Information
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
Authorization for GHC-SCW to Provide Care to Your Minor Child in the Absence of a Parent - Español
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

Ages and Stages Child Check-Up Questionnaire Forms

Nine Months
Eighteen Months
Twenty-Four Months
Thirty-Six Months

Health Insurance Forms

Patient Request for Health Information Form

MyChart Payment & Auto Payment Information - Insurance Premiums

Billing Information Form - English

Billing Information Form - Español

Billing Information Form - kwv tij hmoob

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

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