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.
|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. |