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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 Moundview 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

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.

Gundersen Health System

Gundersen Boscobel Area Hospital and Clinics

Gundersen Harmony Care Center

Gundersen Moundview Hospital and Clinics

Gundersen Palmer Lutheran Hospital and Clinics

Gundersen St. Joseph's Hospital and Clinics

Gundersen Tri-County Care Center

Gundersen Tri-County Hospital and Clinics

Gundersen Tweeten Care Center

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.

Vendor Relationships

Patient Rights & Responsibilities

Amending your MyCare record

If some of your health information on MyCare is not correct, what should you do?

Your MyCare 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 MyCare account, or complete this Amendment form and scan and email it to MyCare@gundersenhealth.org, or send it to: Health Information Management, Gundersen Health System, 1900 South Ave., La Crosse, WI 54601. Your health information is reviewed and updated in your electronic medical record each visit.

Compliance

Advance Care Planning/Power of Attorney for Healthcare

Love + Medicine

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

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