La Crosse, WI 54601 CONSENT RELATING TO TREATMENT OF A ...

Patient Name:
Date of Birth:
Clinic Number:
La Crosse, WI 54601
CONSENT RELATING TO TREATMENT
OF A MINOR PATIENT
To facilitate medical care and treatment of my child,
, (“Minor Patient”), by
Gundersen Clinic, Ltd. and Gundersen Lutheran Medical Center, Inc. (collectively “Gundersen
Lutheran”), the undersigned parent or legal guardian of the Minor Patient hereby agrees as follows:
1. I am a parent or legal guardian of the Minor Patient authorized to make health care decisions on
behalf of the Minor Patient.
2. I authorize Gundersen Lutheran to engage in the following acts:
[Please Check Applicable Box(s)]
Direct Authorization For Treatment By Gundersen Lutheran. I authorize Gundersen
Lutheran to provide the Minor Patient with emergency, urgent and other medical care and
treatment in my absence. (This allows a minor patient to come to an appointment(s)
unaccompanied by parent/guardian/parent substitute.)
Appointment of Parent Substitute to Authorize Care and Treatment for Minor Patient. I
authorize the Parent Substitute designated in paragraph 3 to give informed consent for
emergency, urgent and other medical care and treatment for the Minor Patient.
Release of Information. To ensure that the Parent Substitute has access to Protected
Health Information needed to make informed consent decisions, I authorize Gundersen
Lutheran to provide the Parent Substitute with Protected Health Information relating to the
Minor Patient. “Protected Health Information” means all medical records and treatment
records relating to the Minor Patient which are protected and confidential under 42 C.F.R.
Part 2, Wis. Stat. §§51.30 and 146.82, the Health Insurance Portability and Accountability
Act of 1996, Public Law 104-191 (“HIPAA”), and the Standards for Privacy of Individually
Identifiable Health Information (“HIPAA Privacy Regulations”), 45 C.F.R. Part 160 and Part
164, subparts A and E.
Hospital Discharge. I authorize Gundersen Lutheran to release and discharge the Minor
Patient from the hospital into the custody of the Parent Substitute, and to provide the Parent
Substitute with discharge instructions, medications and other items relating to the Minor
Patient’s follow up care and treatment.
44077 R03/10 CONSENT RELATING TO TREATMENT OF A MINOR PATIENT Page 1 of 2

Patient Name:
Date of Birth:
Clinic Number:
La Crosse, WI 54601
CONSENT RELATING TO TREATMENT
OF A MINOR PATIENT
3. Identification of Parent Substitute. I appoint the following Parent Substitute(s) to obtain
access to Protected Health Information, give informed consent for care and treatment, or
otherwise receive custody of the Minor Patient.
Name Relationship to Minor Phone Number
4. Duration. This authorization is valid for a maximum period of two (2) years from date signed,
unless a shorter duration is specified, commencing on
and
expiring on . This authorization may be revoked at any
time prior to that expiration date by providing Gundersen Lutheran with written notice. Please
send the written notice to Privacy Officer, Health Information Management Systems, Gundersen
Lutheran, Mail Stop FBB-001, 1900 South Avenue, La Crosse, WI 54601.
5. Release. I agree to release Gundersen Lutheran from liability for any claims resulting from
Gundersen Lutheran’s provision of patient care and release of Patient Health Information in
reliance upon this authorization.
I have carefully read and considered this consent form before signing it.
SIGNATURE OF PARENT OR LEGAL GUARDIAN:
Signature
Date
Legal Authority:
Parent of Minor
Legal Guardian
CONTACT INFORMATION CONCERNING PARENT OR LEGAL GUARDIAN:
Name Relationship to Minor Contact Phone Number
Name Relationship to Minor Contact Phone Number
44077 R03/10 CONSENT RELATING TO TREATMENT OF A MINOR PATIENT Page 2 of 2