No-Show Fee Dispute Form

The purpose of this form is to honor the member’s right to dispute a no-show fee they believe was charged in error. The member can also appeal to have the fee waived due to events listed on this form. These events may have prevented the member from going to their scheduled appointment and contacting GHC-SCW of this. GHC-SCW will review the provided information in this form to determine if the fee should be waived.
Name*

First NameLast Name
GHC-SCW Member Number
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Appointment*

MonthDayYear
Date
Time of Appointment

Hour Minutes

AM/PM Option
Name of Provider
Location*

Capitol ClinicEast ClinicHatchery Hill ClinicMadison College Community ClinicSauk Trails ClinicCapitol Regent Behavioral HealthPrinceton Club West
Reason for Dispute

Please indicate the reason why GHC-SCW should consider waiving the no-show fee by selecting one of the options below.
Dane County Weather EmergencyDeath in the FamilySought Higher Level of CareNo-Show Fee Assessed in ErrorDid Not Receive Appointment Reminder in Preferred LanguageOther (Please Provide Details in the Following Field)
Please provide additional feedback or comments for this dispute below:*
Should be Empty: