Patient Forms
Adult Forms
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Child Forms
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Patients
Our Patients
Community Health Centers of Southeastern Iowa, Inc. is dedicated in providing the communities we serve with excellence in medical, dental and behavioral health care that is compassionate, affordable and accessible for patients.
Patients can apply to receive assistance through our Sliding Fee Program that allows patients to pay for their services based on their household income and family size.
Patient Focused
There are many people in our community that do not have health insurance, and there are many in our community who have health insurance, but are still struggling with their portion of health care costs.
We are dedicated to providing a comprehensive set of primary medical and dental care services for patients.
Sliding Fee Program
The sliding fee program allows us to reduce or “slide” the fees for the care of you or your family at CHC/SEIA. You may apply for the program during an appointment to see if you qualify for a discount. Eligibility is based on:
Family Income
Family Size
If your family size or income changes, you may re-verify at any time throughout the year.
In order for an application to be reviewed, persons applying must provide documentation:
Check stub
W2 or W9
Social Security Benefits
Retirement benefits
Disability benefits
Unemployment
Workers Compensation benefits
Veterans benefits (FIP;etc.)
Alimony/Widowers benefit
Student loans
Military family allotments
Most recent tax return
How can I Apply
Once you become a patient at CHC/SEIA, a Patient Service Representative will be available to meet with you at your visit to help you enroll in the Sliding Fee Program.
What can I bring for proof of income?
At least one consecutive MONTH of most recent paycheck stubs
Current personal income tax return
Unemployment benefit statement
Social Security (SSI) or Disability Income Statement
Other documentation of Income
How much do I owe?
The amount of discount depends on your family size and income. We encourage patients to make regular payments at the time of your visit.
Can I apply for the Sliding Fee Program if I have insurance?
Yes, you can still apply for a discount. The discount will then be applied after any insurance payments. This includes private insurance and Medicare.
Paying Your Bill
We are a federally qualified health center that serves people in need with access to affordable health care. CHC/SEIA is not a free clinic, but we do serve the patients with a variety of income levels and backgrounds. We believe that each patient should participate in their own health and that includes contributing financially to the cost of their care. However no patient will be turned away because they cannot pay.
We offer a sliding fee program to assist you with your medical, behavior health or dental cost. We are able to offer this program because of the generosity of grants and private donations, and we sincerely appreciate this support so we can build a healthier community for all; no patient will be turned away because they are unable to pay.
Methods of Payment
We accept cash, checks, debit cards, and credit cards (Visa; Mastercard).
Needs-Based Consideration
CHC/SEIA encourage our patients setup payment plans, if they have personal financial situations where patient payment cannot be made at the time of service.
I need to contact Account Services
You can contact Billing Office by calling 844-843-7942
Where do I send my payment?
Community Health Centers of Southeastern Iowa, Inc.
1618 Main St.
Keokuk, IA 52632
Can, I pay my bill online?
You can pay your bill online at the following link:
I need a payment plan
You can call our Accounting Services Department to discuss a payment plan that works with your budget at 844-843-7942.
I need health insurance
We have Certified Outreach and Enrollment Specialists that can help you with the Affordable Care Act and obtaining health insurance as required by law. If your income is below a certain level, you are not required to buy insurance. Use the tools available on Healthcare.gov to learn more about your eligibility and/or contact one of our Certified Application Counselors at 319-753-2300 to schedule an appointment. They are here to assist you, you don’t have to be a CHC/SEIA patient, and each appointment is free. The ACA law also provides financial assistance to those who qualify based on family size and income.
Privacy Information
Notice of Client Privacy Rights
This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please read it carefully.
This notice applies to all of the records of your care generated by CHC/SEIA, whether made by CHC/SEIA or an associated provider. Our polices on protecting your health information extend to all professional and authorized persons who have a need to know to provide care to you. The policies apply to all areas of CHC/SEIA including all CHC/SEIA staff. It also applies to any entity or individuals with whom we contract services, such as referral providers.
To read our Notice on Privacy Practices please click the link below.
Privacy Contact Information
If you have any questions about this notice or wish to receive a copy, please contact CHC/SEIA:
CHC/SEIA
ATTN: CHC/SEIA PRIVACY OFFICER
1706 W. Agency Road
West Burlington, IA 52655
(319) 768-5858
What to bring to your first appointment:
Proof of income (or no income)
If you are going to sign-up for our Sliding Fee Program.
Health records
You can have files transferred to us.
Advanced directive
Only applicable if you have an advanced directive.
Insurance information
Only if applicable. This includes private insurance, Medicare, and Medicaid.
Picture ID
Medications and/or supplements
Bring in current bottles of prescribed medications and/or supplements.
Social security number
Minor patients must be accompanied by parent at first appointment
Step-parent is not allowed to bring to first appointment unless consent to treat is previously signed and individual is listed as authorized person.
Useful Links
- Academy of Nutrition and Dietetics
- Alcohol and Drug Dependency Services
- American Academy of Family Physicians
- American Cancer Society
- American Dental Association
- American Diabetes Association
- American Heart Association National Center
- American Lung Association
- American Red Cross
- Center for Disease Control (CDC): 1-800-232-4636
- Des Moines County Health Department
- DHS Iowa
- Hancock County Health Department
- Henry County Health Department
- Illinois Primary Health Care Association
- Iowa Department of Public Health
- Iowa Primary Care Association
- Lee County Health Department
- Louisa County Health Department
- Medicare
- MedlinePlus
- National Association of Community Health Centers
- National Cancer Institute
- National Institutes of Health
- National Network for Immunization Information
- Reach out and Read National Program
- RxList
- Suicide and Crisis Hotline: 1-800-332-4224
- US Department of Health & Human Resources
- US Food and Drug Administration (FDA)
- WebMD
Talk With Us
To schedule an appointment; call the following clinic sites:
West Burlington Medical, Pediatric and Dental Clinic
319-768-5858
Louisa County Medical and Dental Clinic
319-728-7400
Keokuk Medical and Dental Clinic
319-524-5734