Forms and Notices

• Durable Power of Attorney for Health Care Decisions (Medical Power of Attorney)

In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability and reprisal or retaliation for prior civil rights activity. (Not all prohibited bases apply to all programs.)

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape and American Sign Language) should contact the responsible State or local Agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 844-8339.

This institution is an equal opportunity provider and employer. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at https://www.ascr.usda.gov/filing-program-discrimination-complaint-usda-customer, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. The completed AD-3027 form or letter must be submitted to USDA by:

Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; or

Fax: (833) 256-1665 or (202) 690-7442; or

Email: program.intake@usda.gov

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the law, health care providers need to give patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises or call (319) 352-4120.

IPOST is a standard medical order, recognized statewide, which gives you control over the treatment you want. The IPOST form can be completed by anyone, regardless of age, who has a chronic critical medical condition or who is frail and elderly or has a terminal illness (less than one year life expectancy).

• Iowa Physician Orders for Scope of Treatment

Our Lost & Found is located at the green entrance registration desk. Items are kept for 60 days.

Money problems should never stop you from getting necessary medical care. Your job may offer a health plan, but it might not cover some of the care you need. Maybe unemployment has made it hard for you to make ends meet, and the bills are piling up. In spite of these problems, we may be able to help.

Financial Assistance Program

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

Your Rights and Protections Against Surprise Medical Bills

As a recipient of Federal financial assistance, the health center does not exclude, deny benefits to or otherwise discriminate against any person on the basis of race, color, national origin, disability or age in admission to, participation in or receipt of the services and benefits under any of its programs and activities, whether carried out by the health center providers directly or through a contractor or any other entity with which the health center providers arrange to carry out its programs and activities.

Waverly Health Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex (consistent with the scope of sex discrimination described at 45 CFR § 92.101(a)(2)).  Waverly Health Center does not exclude people or treat them less favorably because of race, color, national origin, age, disability or sex.

• Non-Discrimination Policy Based on Limited English Proficiency

This institution is an equal opportunity provider and employer. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at Complaint Form, or at any USDA office or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov.

• Patient Privacy Notice

To direct Waverly Health Center to obtain your medical record information from another facility or provider:

• Authorization to Disclose Protected Health Information (Electronic Submission)
• Authorization to Disclose Protected Health Information (Printable Form)

To request copies of your medical record for your personal use or to direct Waverly Health Center to send your medical record information to another provider or facility:

• Request to Access Protected Health Information (Electronic Submission)
• Request to Access Protected Health Information (Printable Form)

Waverly Health Center is a tobacco- and nicotine-free campus. The use of tobacco or nicotine-containing products, including e-cigarettes, is not allowed on our grounds and in our buildings.

We are a Weapons-Free campus. Weapons are not allowed on our grounds and in our buildings.

• Website Terms of Use

• Patients Rights and Responsibilities (English)
• Patients Rights and Responsibilities (Spanish)