PATIENT INFORMATION AND RESPONSIBILITIES

Community Health Center of Fort Dodge (CHCFD) respects each patient and is dedicated to giving the best care possible. Patient Rights and Responsibilities explain what you can expect from us, and in turn, what we expect of you.

As a patient, you have the right to:

...Take part in your health care and treatment
...Know the names of the people caring for you
...Be treated with respect and dignity in a safe and private setting
...Be informed about your illness and treatment, including options for your care
...Change medical providers at CHCFD
...Get another opinion about your illness or treatment
...Privacy of your health records
...Talk with the Clinic Manager about any questions or problems with your care
...Know about services available through CHCFD
...Respect for your cultural, social, spiritual and personal values and beliefs
...Know about legal reporting requirements
...Ask for special arrangements if you have a disability
...Ask for help with a living will or durable power of attorney for health care
...Refuse treatment, care, and services as allowed by law
...Know the cost of your care and ways you may pay for your care
...Refuse to be included in any research program without limiting medical care or treatment

As a patient, you have the responsibility to:

...Tell your medical provider about your illness or problems
...Ask questions about your illness or care
...Show respect to both care givers and other patients
...Cancel or reschedule appointments so that another person may have that time slot
...Pay your sliding fee at time of service
...Pay your insurance co-pay at time of service and all other charges by the due date.
...Use medications or medical devices for yourself only
...Inform the medical provider if symptoms persist or worsen or you have an unexpected reaction to a medication
...Give written permission to release your medical records to CHCFD
...Provide CHCFD a copy of your living will or durable power of attorney for healthcare matters

Appointments

Advanced appointments are preferred. However, for urgent needs, efforts will be made for you to see a doctor that day.

Please be prepared to provide the following information:

...Name
...Date of Birth
...Phone number
...Description of medical problem

Your visit will be scheduled as soon as possible. Please call the clinic, at (515) 576-6500, if you are unable to make your scheduled appointment. Children under age 18 need to be accompanied by a parent or an adult who has written permission from the parent to sign the clinic's treatment contract.

Sliding Fee Discount

Patients without insurance or with high deductibles or Co-Pay may qualify for a discount based on household size and income. You must apply for the discount .
When calling for your first appointment schedule a financial aid appointment.
Bring your current tax return and the last 30 days of pay stubs for entire household to your financial aid appointment for sliding fee evaluation and discount determination, or ask about other options for verification, if none of these are available.
Sliding fee scales need to be reapplied for on a yearly basis or if household size/income changes.
Be prepared to pay the required Minimum Fee and additional sliding fee charges at your visit.
If you have insurance, please bring your ID card to all appointments and inform staff of any changes in coverage.

MEDICAL SERVICE FEES
Sliding Fee Discount Minimum Fee = $15 per visit

Additional fees, depending on where the patient fits on the Sliding Fee Discount scale may apply. For example, if the patient receives a 90% discount on services rendered and the total charge for the services received is $200, there will be an additional $5 fee due.

Please ask your CHCFD Health Care Staff for clarification.

LABORATORY SERVICE FEES
Sliding Fee Discount Minimum Fee = $10 per visit

Additional fees, depending on where the patient fits on the Sliding Fee Discount scale may apply. For example, if the patient receives a 90% discount on services rendered and the total charge for the lab test is $150, there will be an additional $5 fee due.

Please ask your CHCFD Health Care Staff for clarification.

MEDICINE ASSISTANCE PROGRAM (MAP)
Administration Fee = $6 per prescription

This fee is charged for service provided by CHCFD personnel. It is not for the cost of the drug.

Many drugs have an alternative generic version which is available in the Community Health Center Pharmacy. Most generic drugs produce the same results as the expensive brand medication and they will cost less over time. Also, many pharmaceutical companies place a limit on the number of months they will provide the drug.

Please ask your CHCFD Health Care Provider if there is an acceptable generic drug that will work as well as the brand drug. In most instances, the medication can be provided at time of visit and most times for a reduced fee.

PHARMACY

The Community Health Center Pharmacy is available for medications prescribed by CHCFD Health Care Providers. Most generic drugs are available at the time of the medical visit for a small fee ranging from $5 to $9; however, not all drugs are within this range. Please ask your CHCFD Health Care provider for an estimate of costs.

The CHCFD Pharmacy can also provide brand name drugs at reduced costs depending on where the patient fits on the Pharmacy Sliding Fee Discount. The CHCFD does not provide free prescription services. Other sources in the community may be available for assistance. Please ask the CHCFD personnel for referrals.

The CHCFD pharmacy will have on-going prescription needs ready for pick up when needed. Please call the CHCFD Pharmacy to verify that the prescription is ready. It can be picked up at the front reception desk after payment has been made. The CHCFD Pharmacist is available for consultation on medications during the hours of: Monday - 5:30 -7:00 p.m. and Wednesday - 5:30 p.m. to 7:00 p.m. Please ask for assistance at these times or if an emergency arises, please call your CHCFD Health Care Provider for assistance.

Insurance Information

We accept health insurance coverage including Medicaid, Medicare, HAWK-i, and private insurance; however, we may be out -of- network., please ask.
Medicaid- You do not pay the $3.00 co-pay for your appointment at the CHCFD. We accept Title 19, Medicaid, and Medipass.
Medicare- We accept standard Medicare assignments. If you qualify for a sliding fee discount, we will apply discount to the charges not covered by Medicare payments.
Private Insurance- We will file your health care claim according to the specific provisions of your Policy.