Below are the forms you may need to access. These may be printed out and brought with you or, in some cases, mailed to the Health Center. Click the name of the form you need to view. Please note that Adobe Reader is required to view these documents. To get the latest version, Click Here.
Notice of Health Information Practices
This notice describes how information about you may be used and disclosed. It also describes how you can get access to this information.
Authorization for the Disclosure of Protected Health Information
This form is used to obtain copies of your medical records or have records sent from another health facility. This form can be sent to us at:
Scenic Bluffs Community Health Center P.O. Box 39 Cashton, WI 54619
Patient Registration Form
This form is to get information on our new patients. It is also used for updating current patient information, or to appoint a parent substitute to authorize care
Substituted Consent for Treatment of Minors
If you are unable to bring your child to their appointment, you can give us permission for them to be seen or appoint a parent substitute to authorize care
Consent for Treatment of Adult Ward in Legal Guardian Absence
If an adult is not competent to make their own decisions, a legal guardian (appointed by the court) must consent to treatment. If legal guardian is unable to be present at the appointment, we will need authorization to see them.