Member Appeals Form

Member Appeals Form
Member Name (as printed on membership card):*

First NameLast Name
GHC-SCW Member ID Number*
Six digits
Mailing Address (of person requesting appeal):*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please provide the best number to contact you between 7 a.m. and 5 p.m.
Email
By entering your email, you consent to use email.
YesNo
This request is in regards to a member denial for coverage of the following service(s): *
Please tell us in one sentence what you are appealing. For example: I am appealing the denial of referral 1234567 for coverage of [information from referral letter] or for claim number 12345678 for date of service 01/02/25. Your reason for your appeal and details need to be entered later in this form.
YesNo
We will send appeals communication through your GHC MyChart account.

Service #1*
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Service #2
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Service #3
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Service #4
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Service #5
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Service #6
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Service #7
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Service #8
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Please enter additional services here:
Please add any additional information which supports your belief that GHC-SCW should authorize payment for these services.
You will need to contact your providers and acquire copies of all medical records that apply to your appeal.

Attach them to this form below.

GHC-SCW can only access records from GHC-SCW-owned clinics
(Capitol, East, Hatchery Hill, Madison College and Sauk Trails Clinics).
Upload any additional support documents or medical records here:

Cancelof

Release of Information for Appeal Process

I understand that GHC-SCW will discuss information and disclose documents to the investigation and resolution of my appeal with internal and external staff or individuals as deemed necessary.
Full Name*
As printed on Membership Card
Member's Signature*

Clear
Today's Date

MonthDayYear
Date
I am filling out this appeal on behalf of the member
Authorization for a representative to act on your behalf in the appeal process
I First Name Last Name give First Name Last Name authorization to act on my behalf in the appeals process. All of my appeal/medical information may be shared with my representative.
Member's Signature

Clear
Authorized Representative's Name:

First NameLast Name
Relationship to Member:
Authorized Representative's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please provide the best number to contact you between 7 a.m. and 5 p.m.
Email
By entering your email, you consent to use email.
Should be Empty: