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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

Authorization to Release Medical Records from GHC-SCW (Spanish)

Authorization to Receive Medical Records From Another Facility

Authorization to Receive Medical Records From Another Facility (Spanish)
Authorization to Release Payment Information

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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