Forms

Below, you’ll find essential forms and documents providers need to best serve our members.

Note: You may need to download Adobe Acrobat Reader to open these files.

Practice Changes

• Provider Education Attestation Form
  Use this form to provide an attestation of completing education requirements.
• Provider Maintenance Form
  Use the Provider Portal to alert CGHC to changes in your practice. To locate this form, log in to the portal and select “Provider Maintenance” from the navigation bar.

Pharmacy Prior Authorization Forms

• Navigate Pharmacy Prior Authorization Request Form
  Submit this form for prior authorization requests for pharmacy benefit medications.
• Navigate Pharmacy Operations Specialty Prior Authorization Request Form
  Submit this form for prior authorization requests for specialty medications, including physician-administered medications.
  
• Navigate Pharmacy Operations Facility Change Request Form
  Submit this form to request a change to the servicing provider for an existing physician-administered medication authorization.
  
• Navigate Compound Prior Authorization Form
  Submit this form for prior authorization requests for multi-ingredient compound medications.
  

Medical Prior Authorization Forms

• Navigate Wisconsin Provider Medical Prior Authorization Request Form
  Submit this this form for medical Prior Authorization requests

Disputes & Appeals Forms

• Navigate Appointment of Representative to File an Appeal on Patient/Member's Behalf
  Submit this form to request an appeal on behalf of a member.
• Navigate Provider Expedited Appeal Form

Fraud, Waste and Abuse Form

• Fraud, Waste and Abuse Online Reporting
  Submit this form to report suspected fraud, waste or abuse.