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.
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Form
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Purpose
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Example
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Communication Authorization
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Authorization for Prairie Clinic to discuss my condition with designated individual(s).
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If you want your provider to be able to discuss your health with your spouse, adult child, caregiver or other person(s).
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Confidential Communication
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To request alternate (confidential) communication with the clinic.
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If you want the clinic to call you on your cell phone instead of your home phone for sensitive lab results.
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Information Release
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To request copies of your medical record.
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If you are moving and want to transfer your medical records to another clinic.
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Information Release Revocation
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Revocation of the Authorization for Prairie Clinic to send your medical record.
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If you were sharing health information for a court case or don't want additional medical records sent.
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Information Amendment
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To amend your medical record.
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If you want to request a change to your medical record.
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Other Forms
Authorization for Prairie Clinic to discuss my condition with designated individual(s).
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Form
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Purpose
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Example
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| Advanced Directives |
Advanced directives in case you are incapacitated. |
If you do not want to be resuscitated.
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| Job Application |
Employment application. |
If you would like to work at Prairie Clinic.
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