forms & resources
707 S UNIVERSITY AVE \ BEAVER DAM WI 53916 \ 920-887-7181
Authorization Form for Use and Disclosure of Health Care Information
A completed form signed by you and your legal guardian is required to release your information. You may fax your completed form to us at 920-887-6691 or mail to us at:
Marshfield Medical Center-Beaver Dam
Health Information Management
707 S. University Ave.
Beaver Dam, WI 53916
Access to Medical Records (Patient Portals)
Marshfield Medical Center-Beaver Dam
Patient Registration Forms (MMC-BD Medical Clinics)
Chiropractic Clinic New Patient Registration Form
Financial Assistance
Application DOWNLOAD FORM 
Instructions (English) DOWNLOAD FORM
Instructions (Spanish) DOWNLOAD FORM
Community Care Policy DOWNLOAD FORM
Personal Medication Listing
Notice of Privacy Practices
(English) DOWNLOAD
(Spanish) DOWNLOAD
(Hmong) DOWNLOAD
(Somali) DOWNLOAD
Patient Rights and Responsibilities
(English) DOWNLOAD
(Spanish) DOWNLOAD
(Hmong) DOWNLOAD
Patient Information Guide
Hospital Pricing
The federal government requires each hospital to post on its website a list of its standard charges for each inpatient and outpatient service and item provided by the hospital. Each hospital is also required to make available their standard (median) charge for diagnosis-related groups (DRGs) which are used to bill for inpatient hospitalization services. These lists are available in a machine-readable format. The published price transparency spreadsheet is available HERE and the DRG Category for Inpatient Hospitalization with Median price spreadsheet is available HERE.
For information that would help you estimate the cost of your care or the amount you might owe for your care, please contact our patient financial services staff at 920 887-5920. You can find information about our Financial Assistance Policies here. To help our patients better understand healthcare services, the cost of their care, and comparison shop between hospitals, additional information is available at www.wipricepoint.org.
Price Point
Price Point allows health care consumers to receive basic, facility-specific information about healthcare services and charges. Learn more
Act 16 Pricing Information
COVID-19 Pricing
During the COVID-19 emergency period declared by the Public Health Act, providers are required to make public the cash price for the diagnostic test for COVID-19 [Reference: CARES Act Sec. 3202].
COVID-19 Diagnostic Test Cash Price: $108
Insurance should cover without any patient out of pocket costs such as copays or deductibles per the CARES Act. It is always best to verify the cost or coverage of services with your insurance provider.