MemberForms

MEMBER FORMS

Accident Questionnaires

Other Coverage Questionnaires

Privacy Forms

Senior Preferred Forms

Senior Choice Forms

Other

Completed forms can be mailed or faxed to:

Gundersen Health Plan
Mail stop: NCA2-01
1900 South Avenue
La Crosse, WI 54601 

Fax: (608) 775-8091

This web page was last updated on June 5, 2015.

MEMBER FORMS

On this page you will find links to the forms that Gundersen Health Plan members need most often. These forms are sometimes required to verify information such as other coverage, student status or designated representatives. 

If you have a question about a form, please contact Customer Service.