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
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
Notice of Privacy Practices
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.
Commonly Used Languages
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.
Gundersen Health System - all locations
Patient Rights & Responsibilities
Patients Rights & Responsibilities - all locations
Amending your MyChart record
If some of your health information on MyChart is not correct, what should you do?
Your MyChart information comes directly from your electronic medical record. To correct any inaccurate information please contact our Health Information Management medical records office at (608) 775-3199, send a customer service message through your MyChart account, or 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.
Advance Care Planning/Power of Attorney for Healthcare
Gundersen Health Accountable Care Organization (ACO)
About Gundersen Health ACO