Forms
- Durable Power of Attorney for Health Care Decisions (Medical Power of Attorney) (121)
- Declaration Relating to Life-Sustaining Procedures (Living Will) and Durable Power of Attorney for Health Care Decisions (Medical Power of Attorney) (123)
Your Rights and Responsibilities as a Patient
- Waverly Health Center's Patient Rights and Responsibilities
- Waverly Health Center's Patient Rights and Responsibilities (Spanish)
Patient Privacy (HIPAA)
To have Waverly Health Center send your records to another facility or provider:
Request and sign electronically: Authorization to Disclose Protected Health Information
Print a hard copy of this authorization: Authorization to Disclose Protected Health Information
To request copies of your medical record for your information or to hand deliver to another facility or provider:
Request and sign electronically: Request to Access Protected Health Information
Print a hard copy of this access form: Request to Access Protected Health Information
Non-Discrimination Statements
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.
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.
No Surprises Act
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
Good Faith Estimates
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 don’t 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 1 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.
Iowa Physician Orders for Scope of Treatment
IPOST Information
Tobacco- and Nicotine-Free Campus
We are a tobacco- and nicotine-free campus. The use of tobacco or nicotine-containing products is not allowed on our grounds and in our buildings.
Weapons-Free Campus
We are a WEAPONS-FREE campus. Weapons are not allowed on our grounds and in our buildings.
Lost & Found
Our Lost & Found is located at the green entrance registration desk. Items are kept for 60 days.
