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

Vendor Relationships

Patient Rights & Responsibilities

Love + Medicine

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

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