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Health and Wellness Center
PATIENT FORMS LIST

Below is a list of patient forms. All of the forms downloaded, printed sent directly to the Compliance Coordinator/HIPAA Privacy Officer. Patient information is maintained in a confidential manner - complaints and grievances are investigated in accordance with HIPAA regulations and clinic policies and procedures.

Completed forms can be sent to:

Health and Wellness Center
Linda Sturnot, Compliance Coordinator
PO BOX 396
Crandon, WI 54520
phone: (715) 478-4356
fax: (715) 478-4493

Patient Forms

Authorization for Release of
Protected Health Information

Authorization for Release of
PHI / Behavioral Health

Designation of Individuals Permitted to Receive
Protected Health Information for Purpose of
Involvement in Health Care

HIPAA Complaint Form

Patient Request for Alternate Means
of Communication Form

Patient Complaint & Grievance Form

Patient Request for Restriction of
Use and Disclosure of Protected Health Information

Patient Satisfaction Survey

Patient Suggestions

Request for Amendment of Medical Record

Substituted Consent For Treatment of Minors 

 

 

 

 

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