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Forms
> Forms
Physical Forms
Privacy Forms
Please read Prairie Clinic's Notice of Privacy Practices first.
To use the forms print, complete, sign, date and send the form(s) to:
Prairie Clinic S.C., 112 Helen Street, Sauk City, WI 53583.
| Form | Purpose | Example |
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| Communication Authorization | Authorization for Prairie Clinic to discuss my condition with designated individual(s). | If you want your provider to be able to discuss your health with your spouse, adult child, caregiver or other person(s). |
| Confidential Communication | To request alternate (confidential) communication with the clinic. | If you want the clinic to call you on your cell phone instead of your home phone for sensitive lab results. |
| Information Release | To request copies of your medical record. | If you are moving and want to transfer your medical records to another clinic. |
| Information Release Revocation | Revocation of the Authorization for Prairie Clinic to send your medical record. | If you were sharing health information for a court case or don't want additional medical records sent. |
| Information Amendment | To amend your medical record. | If you want to request a change to your medical record. |
Other Forms
| Form | Purpose | Example |
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| Advanced Directives | Advanced directives in case you are incapacitated. | If you do not want to be resuscitated. |
| Job Application | Employment application. | If you would like to work at Prairie Clinic. |
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