Forms

How to Obtain Copies of Your Medical Records

In order to obtain copies of your medical records, please download and complete the “Authorization for the Disclosure of Protected Health Information” and send it to:
    Gundersen Health System
    Medical Records
    1900 South Avenue, AVS-001
    La Crosse, WI 54601

Authorizations may also be faxed to (608) 775-4706.

Turnaround Time

It takes approximately 3-5 days to complete a request once it has been received. If you need your request sooner, please contact us. 

Copy Fees

There is no charge for copies of your health care records if they are mailed directly to another provider or health care facility. In all other cases, there may be a copying charge to receive copies of medical records. Please contact the Medical Records Department for specific copy fees.

Picking Up Health Care Records

If you plan to pick up copies of your medical records, you must provide us with photo identification for verification purposes. If you are unable to pick up your own records and someone else is picking them up for you, please send a note giving Gundersen permission to provide your medical records to that person.

Right to Amend Your Protected Health Information

If you feel that your medical records are incorrect or incomplete, you may ask us to amend that information. You have the right to request an amendment for as long as the information is kept by or for Gundersen Health System. If you are requesting an amendment to your medical record, please download, complete and return this form to:

    Gundersen Health System
    HIM Coordinator
    1900 South Avenue, AVS-001
    La Crosse, WI 54601
In certain cases, we may deny your request for an amendment if information: (1) was not created by us, if the person or entity that created the information is no longer available to make the amendment; (2) is not part of the health information kept by or for Gundersen Health System; (3) is not part of the information which you would be permitted to inspect and copy; or (4) is accurate and complete.

Authorization for Verbal Communication of Health Information

Patients have an opportunity to sign an authorization that will authorize Gundersen to contact a patient at home and leave detailed messages on their answering machine or with someone else they may have specifically authorized us to share their healthcare information with. In the event we need to reschedule an appointment or change a medication, we would also able to leave detailed information instead of a generic message. If you are requesting to have this form on file, please download, complete and return this form to:
    Gundersen Health System
    Medical Records
    1900 South Avenue, AVS-001
    La Crosse, WI 54601

Revocation of an Authorization

You may revoke an authorization, in writing, at any time. You understand that we are unable to take back any disclosures we have already made with your authorization. If you wish to revoke a previously signed authorization, please download, complete and return this form to:
    Gundersen Health System
    Medical Records
    1900 South Avenue, AVS-001
    La Crosse, WI 54601

Right to Receive an Accounting of Disclosures

You have a right to request an "accounting of disclosures." This is a list of those people with whom Gundersen may have shared your health information, with the exception of information shared for purposes of treatment, payment or health care operations or when you have provided us with an authorization to do so. We will provide the list at no cost once during each 12-month period. For any additional requests, we may charge you a fee for the cost of providing the list. We will notify you of the fee and you may choose to withdraw or modify your request at that time before any costs are incurred. To request an accounting of disclosures, please download, complete and return this form to:
    Gundersen Health System
    Medical Records
    1900 South Avenue, AVS-001
    La Crosse, WI 54601
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