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If you would like to obtain copies of your Group Health Cooperative of South Central Wisconsin (GHC-SCW) billing and/or co-pay information, please take the following steps:

  • Download and print the Authorization to Release Payment Information.
  • Complete the patient name, GHC-SCW#, Daytime Phone # and Date of Birth.
  • Complete the name and address of the person or facility that the information is to be released to.
  • Check the purpose of the disclosure.
  • Check the information to be disclosed.
  • Review your rights regarding the authorization.
  • Review the expiration date of the authorization. If you would like a different expiration date, please indicate.
  • Review the information regarding disclosure for special consent.
  • Obtain the signature of the patient or legal representative, indicate the relationship to the patient, if applicable, print the patient’s name and date the signature.
  • Mail or fax the completed form to:

GHC-SCW

Medical Billing Department

1265 John Q. Hammons Drive

Madison, WI 53717

Fax: (608) 828-4856

  • Please do NOT e-mail or scan the completed Authorization to GHC-SCW.
  • Once GHC-SCW receives your completed request, the information is typically available within 3-5 working days.
  • If you have questions or concerns about getting copies of your payment information, please call (608) 251-4138.
  • Please note that you may obtain copies of your medical record by following a separate process specifically for that purpose.

 

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