Forms & Notices

Here are some of the most commonly used forms you may need for your Gundersen appointment. Personalized information and messages to and from your care team can be accessed through your free, secure MyChart account.

There are also notifications and policies that may be of interest.

Consent for treating a minor - Power of Attorney

If a parent can't bring a child in and consent to their medical care

When parents can't attend in person or by phone, the Minor Power of Attorney (POA) form provides a way to delegate parental authority to another trusted adult. It is not mandatory, however appointments may need to be postponed if no parent is available to consent and there is no Minor POA on file.

Regulations change based on your state:
In Wisconsin, if legal custody is shared, both parents must sign the form. If a relative is given permission to bring your child for treatment the form remains valid until the minor turns 18.

In Minnesota and Iowa only one parent needs to sign and the document is only valid for one year or less. Minnesota agreements also must be notarized.

Authorization for treatment/payment/disclosure

Authorization for Verbal Communication
Authorization for Disclosure of Protected Health Information
Patient Authorization and Service Terms | Hmong | Spanish
Patient Right to Restrict Protected Health Information to Health Plan
Authorization for Consolidation of Adult Patient's Accounts (To protect the privacy of our patients, Gundersen lists adult children (over 18) on their parent's account only with written permission from the adult child, using this form. Parents may revoke that arrangement by contacting the Revenue Cycle department.)

Gundersen Boscobel Area Hospital and Clinics

Authorization for Disclosure of Protected Health Information
Patient Right to Access

Gundersen Moundview Hospital and Clinics

Authorization to release/obtain confidential information (Health Information Management)

Gundersen St. Joseph's Hospital and Clinics

Gundersen Tri-County Hospital and Clinics