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Forms

Physical Forms

Male History Form (Male Physical)
Female History Form (Female Physical - except Dr. Schad)

 

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

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

Authorization for Prairie Clinic to discuss my condition with designated individual(s).

Form

Purpose

Example

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