PROVIDER RELATIONS CONTACTS

Request to Join GHC-SCW Network Online Form

Group Health Cooperative of South Central Wisconsin (GHC-SCW) welcomes requests from providers who would like to be contracted to provide services to GHC-SCW Members. GHC-SCW has a multi-disciplinary workgroup that reviews these requests and typically meets on the first Monday of each month. If you are interested in becoming a contracted, GHC-SCW provider, tell us about your practice by completing the form below. Your request will be reviewed at the next workgroup.

General Information

Clinic Name*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Languages Spoken*

NPI

Provider Specialty*

Number of Clinicians on Staff*

Please Give a General Description of the Services You Provide*

What Evidence-Based Treatment Do You Use?*

Number of Prescribers on Staff*

What Age Ranges Do You See?*

What Specific Disorders Do You Treat?*

Contact Information

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Website*

Do You Accept Medicaid?*

YesNo

If you have any attachments that you'd like to include, please use the file upload on this page.