Home | Print | Email | Bookmark | Site Map | TEXT SIZE


Member Forms
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.

Thank you for taking the time to complete the questionnaire(s). If you would like to speak to a customer service representative, please call (608) 775-8007 or (800) 897-1923. For those with hearing impairment, call TTY (800) 947-3529. Our office hours are Monday through Friday from 8 a.m. to 5 p.m.

Accident Questionnaires

Other Coverage Questionnaires

Designated Representative Authorization Questionnaires

Other

Completed forms can be mailed or faxed to:

Gundersen Lutheran Health Plan
1836 South Avenue, Mail Stop: NCA2-01
La Crosse, WI 54601
Fax: (608) 775-8091

 

 

© Copyright 2010