If you are a new patient at Mayo Clinic Health System Franciscan Healthcare , you will need to provide the following information upon registration:
- First, middle and last names (as listed on your birth certificate)
- Date of birth
- Social Security Number (optional)
- Complete address (including apartment, lot or trailer number)
- Home telephone number
- Martial status
- Maiden or previous name
- Employer name, address and telephone number
- Emergency contact name and number
- Insurance information
All patients should arrive approximately 20 minutes prior to their appointment to allow time to complete the necessary forms. If you need to cancel an appointment, please call at least 24 hours in advance.
Copies of your Medical Records and Permitting Others to View Your Medical Information
Download and complete the form to request copies of your medical records. This form is used to provide us with your permission to share your medical records with another health care provider or system (make copies and send to them) or with another individual -- such as a family member -- who you wish to assist with your care.
If your records are on the La Crosse Campus, Arcadia Campus or Sparta Campus, please mail or fax the completed form to those locations. If your records are at any other Mayo Clinic Health System Franciscan Healthcare location (regional clinics), please send your request to the La Crosse Campus Clinic.
Medical Record Fax Numbers:
- La Crosse Campus Clinic - 608-392-9897
- La Crosse Campus Hospital - 608-392-9799
- Arcadia Campus - 608-323-3795
- Sparta Campus - 608-269-1017
A central point where patients (or their designees) may view copies of their medical records is open on the first floor of the La Crosse Hospital building. This service is near the Registration offices just to the left of the information desk at the hospital main entrance. Both clinic and hospital records are available at this location. Patients (or their designees) can also sign authorization forms, pick up copies of their records and have other questions about records management answered. It is staffed from 8 a.m. to 5 p.m. Monday through Friday and the telephone number is 608-392-9137.
Requesting Changes (Amendments) to your Medical Record
It is the policy of Mayo Clinic Health System Franciscan Healthcare to honor a patient’s right to request an amendment or correction to their protected health information if they feel that the information is incomplete or inaccurate. The patient has the right to request an amendment of their protected health information for as long as that information is maintained in the designated record set. Patient requests for amendment of protected health information shall be made in writing to Mayo Clinic Health System Franciscan Healthcare and clearly identify the information to be amended, as well as the reasons for the amendment.
Complete and submit this form to request a change to your medical record. Please mail to:
Mayo Clinic Health System Franciscan Healthcare
700 West Avenue South
La Crosse, WI 54601
or you may hand-deliver to the Release of Information office on the first floor of the La Crosse Campus Hospital Building (near the information desk). This form is applicable to records at all Mayo Clinic Health System – Franciscan Healthcare locations.
Release of Financial Information:
You must authorize release of financial information for us to discuss your patient accounts with any other party. You must download and complete the designated form and have it notarized. The form must then be returned to Mayo Clinic Health System Franciscan Healthcare Patient Financial Services, 700 West Avenue South, La Crosse, WI 54601
Additional Information and Consent Forms for Health Tradition Health Plan Members:
Authorization for Disclosure of Information - This form allows you appoint a representative who can act on your behalf to inquire about claims or referrals, resolve issues for you, make changes to your account or file a complaint on your behalf. You must indicate the information that can be discussed with the representative as well as those that cannot. You can limit the types of information and the time frames for the authorization.
Regulations stipulated by the Health Insurance Portability and Accountability Act (HIPAA) and Wisconsin State Law require that authorizations be in place for adults to inquire on their child’s account based on the ages and subjects below:
Medical, Claims and Referral Information
Any adult over eighteen (18) years of age must give authorization. Parents of children younger than 18 years do not need authorization. Please note that college students must authorize their parents to act for them. Special rules apply to mental health or family planning related information.
- Mental Health Services - Any member over fourteen (14) years of age must give authorization. In order for the parent or legal guardian to inquire about any information or service related to the child, the child must sign an Authorization to Release Information form.
- Family Planning Services - Any member over fourteen (14) years of age must give authorization. In order for the parent or legal guardian to inquire about any information or service related to the child, the child must sign an Authorization For Disclosure of Information form.
Members are required to fill out these two forms if he/she chooses to appoint a representative to act on their behalf in the Health Tradition’s Appeals and Grievance process.
Revocation of Authorization for Disclosure of Information - You have the right to revoke an Authorization at any time. To revoke a previously submitted authorization, fill out the revocation form and return it to Health Tradition.
Please visit the Health Tradition Health Plan web for additional information.