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Clinic Policies


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 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:

  1. 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.

  2. 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.


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 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 a six-month period 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 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 health care 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 at Mental Health-Southeast Iowa Regional Medical Center staff member. Our goal is to serve you the best way we can.

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