Clinical Documentation PDF UPLOAD FORM

Transition of Care Form Upload

Welcome to Group Health Cooperative of South Central Wisconsin (GHC-SCW) Regardless of the clinic you choose, we can assist you with your health care needs during this transition period. To facilitate this, please complete the form below for each person in your family covered by this policy. If you have any questions, please contact the Care Management Department at (608) 257-5294.
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Welcome to Group Health Cooperative of South Central Wisconsin (GHC-SCW). Please use this form to upload additional documentation to support a prior authorization request you have already submitted. Please be sure to provide helpful identifying information, such as the referral number or claim number, that this documentation is for.
Patient Name*

First NameLast Name
Patient's Member Number:*
Provider Name*

First NameLast Name
Provider Email*
example@example.com
Provider Phone Number*
Please enter a valid phone number.
Additional Comments (Please include information, such as the referral number or claim number, that this documentation is for.)*
Please upload your clinical documentation forms below.

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Transition of Care Form Upload