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.