- Member Claim Form
- Explanation of Benefits (EOB) Samples and Information
- Employer Group/Commercial Accident Questionnaire
- Senior Preferred Accident Questionnaire
- BadgerCare Plus Accident Questionnaire
Other Coverage Questionnaires
- Authorization for Disclosure of Protected Health Information
- Appointment of Authorized Representative for Appeals Form
Senior Preferred Forms
- To request an initial Part D coverage determination or exception, please use this form:
- To request a Part D redetermination, first-level appeal, please use this form:
- Appointment of Representative Statement form (If you would like to appoint a representative to act on your behalf in requesting a coverage determination, appeal or grievance, please refer to this form).
Senior Choice Forms
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.
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.