Patient Forms & Online Services

Please return completed forms to your provider at your next appointment or mail them to:

Marshfield Clinic
Health Information Management
1000 Oak Avenue
Marshfield, WI 54449

Consent for Treatment of Minors in Parent/Legal Guardian Absence (PDF 37 KB opens in new window)
Marshfield Clinic requires that a parent or legal guardian consent to the care of minor children. In the event that a parent or legal guardian is unable to consent to care the parent or legal guardian may delegate the right to consent to another adult.

Access to Health Information Request (PDF 33 KB opens in new window)
Patients have a right to access their medical record to inspect and obtain a copy. Marshfield Clinic can deny this request for a number of reasons. Marshfield Clinic will provide written notice of the decision within 60 days.

Amendment/Correction of Health Information Request (PDF 155 KB opens in new window)
Patients have the right to request that the Marshfield Clinic amend health information that is in the medical record. Marshfield Clinic can deny this request for a number of reasons, including if the information is accurate and complete. Marshfield Clinic will provide written notice of the decision within 60 days.

Restriction of Health Information Request (PDF 33 KB opens in new window)
Patients have a right to request that the use or disclosure of their health information to carry out treatment, payment or health care operations be restricted. Marshfield Clinic is not required to agree to the requested restrictions.

Release of Information Authorization (PDF 108 KB opens in new window)
Patients can authorize the release of their confidential health information using a form that meets the requirements of both state and federal law.

Share Medical Information Authorization (PDF 108 KB opens in new window)
Patients can authorize the release of their confidential health information to a family member using a form that meets the requirements of both state and federal law.

Accounting of Disclosures of Health Information Request (PDF 34 KB opens in new window)
Patients have the right to receive an accounting of disclosures of health information made by Marshfield Clinic in the prior 6 years, except for certain disclosures such as authorized disclosures or disclosures made to carry out treatment, payment and health care operations.

Revocation Written Notice (PDF 20 KB opens in new window)
Patients can revoke or cancel a previous authorization for the release of their health information so that future releases will stop.

Consent for Treatment of Adult Ward in Legal Guardian Absence (PDF 56 KB opens in new window)
To comply with Wisconsin law, Marshfield Clinic requires that a legal guardian (guardian appointed by a court) consent to the care of their court appointed ward. In the event that a legal guardian is unable to consent to care the legal guardian may delegate the right to consent to another adult. In the event that the ward presents for a non-urgent medical appointment without a legal guardian or a signed consent, treatment may be denied.

Notice of Privacy Practices
Patients have a right to adequate notice of how Marshfield Clinic will use or disclosure their confidential health information. This notice also explains the patient’s rights and Marshfield Clinic’s duties with respect to confidential health information.