Forms & Notices
Here are some of the most commonly used forms you may need for your Gundersen appointment. You can also find notifications and policies. Personalized information and messages to and from your care team can be accessed through your free, secure MyChart account.
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 the document, and it is only valid for one year or less. Minnesota agreements also must be notarized.
Authorization for treatment/payment/disclosure
Gundersen Health System
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
Authorization for Disclosure of Protected Health Information
Gundersen Moundview Hospital and Clinics
Authorization for Disclosure of Protected Health Information
Gundersen Palmer Lutheran Hospital and Clinics
Authorization to release/obtain confidential information (Health Information Management)
Gundersen St. Joseph's Hospital and Clinics
Authorization for Disclosure of Protected Health Information
Gundersen Tri-County Hospital and Clinics
Authorization for Disclosure of Protected Health Information
Notice of Privacy Practices
Gundersen Boscobel Area Hospital and Clinics
Gundersen Moundview Hospital and Clinics
Gundersen Palmer Lutheran Hospital and Clinics
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.
Learn more about our Notices of Non-Discrimination for Gundersen Health System.
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. Learn more about the availability of language assistance services in our region.
Vendor Relationships
Patient Rights & Responsibilities
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.