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

Accident Questionnaires

• Commercial and Senior Preferred Accident Questionnaire
• BadgerCare Plus Accident Questionnaire

Other Coverage Questionnaires

• Commercial and Senior Preferred Other Coverage Questionnaire
• BadgerCare Plus Other Coverage Questionnaire

Designated Representative Authorization Questionnaires

• Commercial and BadgerCare Plus Designated Representative Authorization Form
• Senior Preferred Designated Representative Authorization Form

Other

• Dependent Coverage Eligibility Questionnaire
• Enrollee Nominations for Gundersen Lutheran Health Plan Board of Directors

Completed forms should be sent to:

Gundersen Lutheran Health Plan
1836 South Avenue, Mail Stop: NCA2-01
La Crosse, WI 54601