Forms & Notices
Find some of the most commonly used forms, notices and policies needed for your appointment. Personalized information and messages to and from your care team can be accessed through your free and secure MyChart account.
Authorization for Disclosure of Protected Health Information (PHI)
Gundersen Health System: English
Gundersen Boscobel Area Hospital & Clinics: English
Gundersen Moundview Hospital & Clinics: English
Gundersen St. Joseph’s Hospital & Clinics: English
Gundersen Tri-County Hospital & Clinics: English
Communication Consent
Gundersen Health System: English | Hmong | Spanish
Gundersen Boscobel Area Hospital & Clinics: English | Hmong | Spanish
Gundersen Moundview Hospital & Clinics: English | Hmong | Spanish
Gundersen Palmer Lutheran Hospital & Clinics: English | Hmong | Spanish
Gundersen St. Elizabeth's Hospital & Clinics: English | Hmong | Spanish
Gundersen St. Joseph's Hospital & Clinics: English | Hmong | Spanish
Gundersen Tri-County Hospital & Clinics: English | Hmong | Spanish
Conditions of Admission or Authorization for Outpatient Procedures
Gundersen Palmer Lutheran Hospital & Clinics: English
Notice of Non-Discrimination
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.
All locations: Notices of Non-Discrimination
Notice of Privacy Practices
Gundersen Health System: English
Gundersen Boscobel Area Hospital & Clinics: English
Gundersen Moundview Hospital & Clinics: English
Gundersen Palmer Lutheran Hospital & Clinics: English
Gundersen St. Joseph’s Hospital & Clinics: English
Gundersen Tri-County Hospital & Clinics: English
Patient Right of Access
Gundersen Boscobel Area Hospital & Clinics: English
Patient Rights & Responsibilities
All locations: Patient Rights & Responsibilities
Payment Disclosure & Agreement
Gundersen Health System: English | Hmong | Spanish
Gundersen Boscobel Area Hospital & Clinics: English | Hmong | Spanish
Gundersen Moundview Hospital & Clinics: English | Hmong | Spanish
Gundersen Palmer Lutheran Hospital & Clinics: English | Hmong | Spanish
Gundersen St. Elizabeth’s Hospital & Clinics: English | Hmong | Spanish
Gundersen St. Joseph’s Hospital & Clinics: English | Hmong | Spanish
Gundersen Tri-County Hospital & Clinics: English | Hmong | Spanish
Power of Attorney for Treatment of Minor Patient
All locations: English | Hmong | Spanish
When parents can't attend an appointment with their child 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. If you have questions, refer to these instructions and FAQs for parents.
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 the document, and it is only valid for one year or less. Minnesota agreements also must be notarized.
Registration Agreement & Service Terms
Gundersen Health System: English | Hmong | Spanish
Gundersen Boscobel Area Hospital & Clinics: English | Hmong | Spanish
Gundersen Moundview Hospital & Clinics: English | Hmong | Spanish
Gundersen Palmer Lutheran Hospital & Clinics: English | Hmong | Spanish
Gundersen St. Elizabeth’s Hospital & Clinics: English | Hmong | Spanish
Gundersen St. Joseph’s Hospital & Clinics: English | Hmong | Spanish
Gundersen Tri-County Hospital & Clinics: English | Hmong | Spanish
Request to Restrict PHI to Health Plan
Gundersen Health System: English | Hmong | Spanish
Gundersen Boscobel Area Hospital & Clinics: English | Hmong | Spanish
Gundersen Moundview Hospital & Clinics: English | Hmong | Spanish
Gundersen Palmer Lutheran Hospital & Clinics: English | Hmong | Spanish
Gundersen St. Elizabeth’s Hospital & Clinics: English | Hmong | Spanish
Gundersen St. Joseph’s Hospital & Clinics: English | Hmong | Spanish
Gundersen Tri-County Hospital & Clinics: English | Hmong | Spanish
Additional resources
Advance Care Planning/Power of Attorney for Healthcare
Amending your MyChart record
Your MyChart information comes directly from your electronic medical record. If some of your health information on MyChart is not accurate, here's how you can request an update:
- Contact the Health Information Management/Medical Records office at (608) 775-3199
- Send a customer service message through your MyChart account
- Complete this Amendment form and scan and email it to [email protected], or send it to: Health Information Management, Gundersen Health System, 1900 South Ave., Mailstop NCA2-08, La Crosse, WI 54601
Your health information is reviewed and updated in your electronic medical record each visit.
Compliance
Vendor relationships
All locations: Vendor relationships