If you would like to obtain copies of your Group Health Cooperative of South Central Wisconsin (GHC-SCW) medical records, please take the following steps:

• Download and print the Authorization to Release Medical Information from GHC-SCW
• Complete the patient’s name, GHC-SCW#, daytime phone #, and date of birth.
• Complete the name and address of the person/facility that the records are to be released to.
• Check the reason for releasing this information (Purpose of this Disclosure).
• Identify the appropriate dates of service for the records that are to be released.
• Check the appropriate information that is to be released (copied and/or faxed).
• Review your rights for this authorization.
• Review the expiration date of the authorization. If you would like a different expiration date, please indicate.
• Obtain the patient or legal representative’s signature (relationship) and date.
• If this request relates to AIDS/HIV, Mental Health Care, Alcohol/Drug Use, or Development Disabilities, please sign and date under the specified section .
  
• Mail or fax the completed form to:
  
  GHC-SCW
  Attn: Release of Information
  5249 East Terrace Drive
  Madison, WI 53718-8339

Fax (608) 441-3499

• Please do NOT email/scan completed Authorization Form to GHC-SCW.
  
• Once GHC-SCW receives your completed request, we typically have the records ready within 3-5 working days.

If you have any other questions or concerns about getting copies of your medical record, please call (608) 441-3500.