Patient Forms

Doctor holding clipboard with nurse and patient.

Adult Forms

click the following link for adult forms

Pediatrician visiting parents and child in hospital bed

Child Forms

click the following link for child forms


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.

Pediatrician visiting parents and child in hospital bed

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






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 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.

Doctor with checklist at table

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.

Privacy Contact Information

If you have any questions about this notice or wish to receive a copy, please contact CHC/SEIA:


1706 W. Agency Road
West Burlington, IA 52655
(319) 768-5858

Heart in clipboard icon

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.

Doctor holding clipboard with nurse and patient.
Nurse Icon

Talk With Us

To schedule an appointment; call the following clinic sites:


West Burlington Medical, Pediatric and Dental Clinic



Louisa County Medical and Dental Clinic



Keokuk Medical and Dental Clinic



Hamilton Medical Clinic


“Clean place went several times to have a tooth pulled after pain overcame me. They took care of me; worked me in. Very nice and gentle Dentists.”



“Knowledgeable professionals who truly care for our loved ones good health!”



“I love these people at CHC! Great place Good and caring folks.”



“I have been using CHC since 2009. I have had excellent care. The Dental clinic team is awesome. Everybody makes you feel at ease and takes their time with you. I will recommend the whole clinic to all of Southeast Iowa.”