Confidentiality is a priority at all Southeast Iowa Regional Medical Center
locations. During your first visit, you may be asked to sign a release
that allows the provider to communicate about your evaluation to your
referring provider. Information you give to the health system will be
protected according to state and federal law.
Please understand we may request signed authorizations for the release
of information from you to coordinate your health care with other providers
to facilitate payment from your third-party payer. Southeast Iowa Regional
Medical Center will release information about you only according to the
terms of our Privacy Practices. A copy of Privacy Practices is posted
in our clinic and available on request.
Prescription Refills
Please allow 48 to 72 hours for your prescriptions to be refilled. Our
providers may authorize enough medication until your next appointment.
There are two ways get request refills:
Call the West Burlington Clinic at
319-768-3700 and press “1” or call
319-768-3736. Leave your name, medication name and dosage, and telephone number OR
if visiting the Fort Madison Clinic call
319-376-1130.
Call your pharmacy and they will request a refill.
Controlled substances/narcotics will not be refilled early. If you have
questions, please refer to the narcotics contract.
After-hours Emergencies
If you have an emergency when our clinic is closed, please go directly
to the nearest Emergency Department.
Insurance
We will file all insurance. Insurance payments vary depending on insurance
policies, and testing and treatment procedures. Some services and charges
may not be covered by health insurance. It is your responsibility to:
Verify coverage before your appointment.
Check if pre-authorization is required.
Check if the provider you are seeing is in your coverage network
Our insurance specialist does everything possible to pre-check, but it
is your responsibility.
Payment Policy
Payment, including co-payments and deductibles, is expected at the time
of service. Although we bill insurance, the client is responsible for
the payment of fees.
For billing questions, please call Patient Financial Services-Patient Billing at
319-768-3625, option 2. Accounts 120 days past due may be sent to collections. Seriously
delinquent or substantial deviation from this policy without agreement
from Patient Financial Services-Patient Billing may result in termination
of services. Notification of such termination would be given 30 days in
advance to allow time to secure alternative services, during which time
only emergency services will be approved. Our staff can discuss fees with you.
Cancellations and “no-shows”
Keeping appointments is important to your treatment, and it affects other
patients. When you cancel appointments late or fail to show up for appointments,
there isn’t time to schedule another patient who also needs help.
If you must cancel an appointment, please call the office right away. If
our office is closed and your appointment is the next day, leave a message
with our answering service.
Cancelling an appointment less than 24 hours before the appointment is
considered a no-show. You will be charged $25 for each no-show. There
are other consequences, too:
If you have a late cancellation or miss your intake appointment with the
provider, services will be denied.
If you miss three appointments in six months because of late cancellations
or no-shows, we will terminate services.
If you have two consecutive no-show appointments with any provider, we
will terminate services.
Clients whose services are terminated will be provided with recommendations
to other agencies. Southeast Iowa Regional Medical Center will provide
30-day emergency care while you secure alternate care.
Your Responsibilities
You have the responsibility to:
Accept responsibility for your behavior but not the behavior of others.
Carry out assignments given to you by your provider, including reading,
rehabilitation, record keeping, or participation support, and additional
activities.
Discuss problems openly and directly with your provider.
Establish goals with your provider and work actively toward the accomplishment
of those goals while in treatment.
Make appointments to see your provider regularly and keep your appointments.
Participate fully in the prescribed therapy and/or medication program ordered
by your provider.
Pay your fees and keep payment current.
Report accurately the circumstances in your life that may be affecting
your problems
Please speak to your provider if you are dissatisfied with your treatment.
If this is not agreeable, please speak with the clinic manager. If this
fails, please refer to your insurance agreement for the complaint procedures
established by your healthcare provider.
This is an attempt to acquaint you with your rights and responsibilities
as a client. If you have any questions, please feel free to ask a Mental
Health-Southeast Iowa Regional Medical Center staff member. Our goal is
to serve you the best way we can.
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