Forms

Common Patient Forms

For your convenience, we have the most commonly needed patient forms available to print. Talk to the schedulers or your nurse to find out which forms you need at your next appointment.

MyChart Forms

MyChart is a free service that gives you the flexibility to access your health information and other resources on your time and between visits to Winneshiek Medical Center.

Can someone help you manage your health care?

Authorization for Verbal Communication of Health Information

This type of authorization allows adults to give consent for others to receive verbal-only communication on their health care.  You may choose to allow all information to be shared, or you can limit it to things like up-coming appointments, billing, medications, etc.  Common applications of this authorization include parents who pay the medical bills of their college-age children and want the ability to ask questions, people who manage someone else’s health care (such as an elderly parent), and anyone who is on medications that require frequent testing and adjustment.  Authorization for Verbal Communication of Health Information also must be re-instated one year after the signed date.

Medical Power of Attorney

In case you are unable to make decisions in the event of an accident, illness or injury, you may want to consider naming someone you trust as your medical power of attorney.  This person will make medical decisions on your behalf, as recommended by the attending health care provider, and according to your wishes made known to them through the form process or otherwise. Medical Power of Attorney only needs to re-visited if you are changing the person you have named.   If you share the signed Medical Power of Attorney document with us, WMC includes it in your medical record.  It is appropriate for adults of all ages to choose a medical power of attorney.

 

For more information on the various consents available and if they are right for you, talk to your primary health care provider, or call Winneshiek Medical Center at 563-382-2911 and ask to speak with the Health Information Management Department.

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