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Other Gundersen Health System providers may choose not to prescribe opioids and/or other controlled substances not listed in this agreement. I permit my provider to share protected health information. He or she may coordinate my care with other providers. Patient Name Medical Record Number Gundersen Lutheran Medical Center Inc. Gundersen Clinic Ltd. Gundersen Tri-County Hospital and Clinics Gundersen St. Joseph s Hospital and Clinics CHRONIC PAIN MANAGEMENT AGREEMENT This agreement covers...

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Gundersen Luformran Medical Center is a healthcare facility located in the state of Wisconsin.

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Information regarding patient care, services provided, and any incidents or accidents that occurred within the center must be reported.

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