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 MyCare 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...

Power of Attorney for Minors and Parental Instructions

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

Gundersen Health System

Gundersen Boscobel Area Hospital and Clinics

Gundersen Palmer Lutheran Hospital and Clinics

Gundersen St. Joseph's Hospital and Clinics

Gundersen Tri-County Hospital and Clinics

Notice of Privacy Practices

Statement of Nondiscrimination

At Gundersen Health System we respect your right to high quality care with dignity, respect and appreciation of the beliefs and values of each patient. We care for patients without regard to: age, race, ethnicity, ancestry, national origin, creed, religion, culture, language, physical or mental disability, newborn status, socioeconomic status, marital status, sex, sexual orientation, gender identity or expression. That commitment also applies to our regional center locations.

Gundersen Health System

Gundersen Boscobel Area Hospital and Clinics

Gundersen Palmer Lutheran Hospital and Clinics

Gundersen St. Joseph's Hospital and Clinics

Gundersen Tri-County Hospital and Clinics

Gundersen Tweeten Care Center

To assist those with limited English proficiency, explanations about the availability of language assistance has been translated into the most commonly used languages in Wisconsin, Minnesota and Iowa.

Vendor Relationships

Patient Rights & Responsibilities

Compliance

Love + Medicine

Every day, Gundersen Health System delivers great medicine plus a little something extra—we call it Love + Medicine.

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