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.

Athletic Physicals form – Decorah, Iowa, Minnesota
Authorization for Verbal Communication
Authorization to Release Billing Information
Current Visit Information Form (current health summary)
COVID-19 Vaccine Administration Record Form and Checklist
Consent for the Treatment of a Minor
Financial Assistance Application
Patient Family Social History Form (medical history)
Request a copy of your health records for yourself.
Request your records be sent to, or received from, another provider/business.

MyChart forms

MyChart Access Application – Authorization to allow access to the Electronic Medical Record

MyChart Parental/Guardian Access – Requirements and procedures for accessing the Electronic Medical Record of children < 18 years of age

MyChart Incapacitated Patient Access Application – Adult Access to the Electronic Medical Record of an incapacitated patient

MyChart Adult/Adult Access Application – Adult access to the Electronic Medical Record of an adult patient

Electronic Medical Record Sharing “Opt-Out” Notice

Can someone help you manage your health care?

Depending on your situation, you may want to consider giving specific types of consent to people you trust:

patient_formConsent to Treat a Minor 

Parents or guardians can give consent for treatment of a minor.  This may apply if you are leaving town without your children for a few days, have children in daycare, or would appreciate the flexibility of having someone else listed to help out with appointments or other non-urgent needs.   Adults listed on the Consent to Treat a Minor form can authorize diagnostic and/or medical treatment, as recommended by the attending health care provider.  Consent to Treat a Minor expires on December 31 of each year, and must be re-instated on an annual basis.  Note: Anyone can bring a minor child into the 24/7 ER for emergent 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.