Patient Rights and Responsibilities

As a patient, parent or legal guardian of a minor patient, you have a right to:
  • Be treated with respect, consideration and dignity.
  • Respectful care given by competent personnel with consideration of their privacy concerning their medical care.
  • Be given the name of their attending physician, the names of all other physicians directly assisting in their care, and the names and functions of other health care persons having direct contact with the patient.
  • Have records pertaining to their medical care treated as confidential and, except when reviewed by law, patients are given the opportunity to approve or refuse their release.
  • Know what Surgery Center rules and regulations apply to their conduct as a patient.
  • Expect emergency procedures to be implemented without delay.
  • Expedient and professional transfer to another facility when medically necessary and to have the responsible person and the facility that the patient is transferred to be notified prior to transfer.
  • Good quality care and high professional standards that are continually maintained and reviewed.
  • Full information in layman’s terms concerning diagnosis and treatment; if it is not medically advisable to give this information to the patient, the information shall be given to the responsible person on his/her behalf.
  • Receive a second opinion concerning the proposed surgical procedure, if requested.
  • Information on after-hour and emergency care.
  • Give an informed consent to the physician prior to the start of a procedure.
  • Be advised of participation in a medical research program or donor program; the patient shall give consent prior to participation in such a program; a patient may also refuse to continue in a program that has previously given informed consent to participate in.
  • Receive appropriate and timely follow-up information of abnormal findings and tests.
  • Receive appropriate and timely referrals and consultation.
  • Receive information regarding “continuity of care.”
  • Refuse drugs or procedures and have a physician explain the medical consequences of the drugs or procedures.
  • Medical and nursing services without discrimination based upon age, race, color, religion, sex, national origin, handicap, disability, or source of payment.
  • Be given the opportunity to participate in discussions involving their healthcare, except when such participation is contraindicated for medical reasons.
  • Have access to an interpreter whenever possible.
  • Be provided with, upon written request, access to all information contained in their medical record.
  • Accurate information regarding the competence and capabilities of the organization.
  • Receive information regarding methods of expressing suggestions or grievances to the organization.
  • File any complaints/grievances with the administration at The Surgery Center at United Medical Park and receive an appropriate response within ten (10) business days. Contact information for administration is The Surgery Center at United Medical Park – Administration, 1731 W Ridgeway Ave. Waterloo, IA 50701. The phone number is (319) 833-5800.
  • Refer complaints or grievances regarding quality of care, premature discharge, or beneficiary complaints to the Iowa Department of Inspections and Appeals, Health Facilities Division, Lucas State Office Building, Des Moines, IA 50319. The telephone number is (877) 686-0027. Medicare patients may also refer concerns to the Iowa Foundation for Medical Care (IFMC), the Medicare quality improvement organization for Iowa. The IFMC may be reached at (515) 223.2900 or at this address: 6000 Westown Parkway, West Des Moines, IA 50266. Complaints may be referred to the Medicare Beneficiary Ombudsman at
  • Appropriate assessment and management of pain.
  • Participate in their own healthcare decisions except if this is contraindicated due to medical reasons.
  • Information regarding fees for services and payment policies.
  • Be informed of their right to change primary or specialty physicians if other qualified physicians are available.
  • Receive a Patient Privacy Notice which provides an explanation of how their protected health information is utilized and to those that may need to receive it.
  • A verbal and written notice of these patient rights and responsibilities, receive information pertaining to the facility’s policy for advance directives (including a description of applicable state health hand safety laws and if requested, official state advance directive forms), written disclosure of physician financial interests or ownership, all of which must be provided in advance of the procedure.
  • Receive care in a safe setting and one that is free from all forms of abuse or harassment.
As a patient, you have the responsibility to:
  • Provide the Surgery Center staff with complete, accurate health information, any medications including over-the-counter products, dietary supplements and any allergies or sensitivities.
  • Follow instructions given by his/her surgeon, anesthesiologist, and operative care team.
  • Provide a responsible adult to transport the patient home from the facility and remain with him/her for 24 hours if required by the physician.
  • Provide the Surgery Center with all information regarding third-party insurance coverage.
  • Fulfill financial responsibility for all services received as determined by the patient’s insurance carrier.
  • Be respectful of all healthcare providers, staff, and other patients.
  • Inform a facility staff member regarding any of the following:
    • If they feel that their privacy has been violated.
    • If their safety is being threatened.
    • If they feel a need/desire to file a grievance.
Policy on Advance Directives

The Surgery Center at United Medical Park does not recognize advanced directives and will use all measures possible to sustain life. If an emergency transfer did occur, all chart information would be copied and sent with the patient to the hospital. Because of this, if you have an advanced directive, please bring a copy of this to be placed within your medical record at The Surgery Center at United Medical Park.

Physician Financial Interests

A number of physicians have an ownership stake and financial interest in The Surgery Center at United Medical Park. Patients retain the right to choose his or her provider for health care services as well as the option to use another health care facility. Patients will not be treated differently by their physician if he or she chooses to use a different facility. If desired, the physician can provide information about alternative providers. If there are any questions or concerns, please contact The Surgery Center at United Medical Park for assistance.

Accessibility and Non-Discriminatory Notice

Nondiscriminatory Policy
Ensures education of and public awareness of Civil Rights. This facility has agreed to comply with the provisions of the Federal Civil Rights Act of 1964 and the Pennsylvania Human Relations Act and all requirements imposed pursuant thereto to the end that no person shall, on the grounds of race, color, national origin, ancestry, age, sex, religious creed, or disability, be excluded from participation in, be denied benefits of, or otherwise be subject to discrimination in the provision of any care or service.

Civil Rights Compliance
The Surgery Center at United Medical Park complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Surgery Center at United Medical Park does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Language Assistance
The Surgery Center at United Medical Park provides services to people with disabilities to communicate effectively with us, such as:

  • Qualified sign language interpreters
  • Written information if other formats can be requested and made readily available, other formats may include (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages

If you need these services, contact the administration office.

If you believe that that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Allison Lundy, CEO
The Surgery Center at United Medical Park
1731 W Ridgeway Ave.
Waterloo, IA 50701     
(319) 833-5800

You can file a grievance in person or by mail, fax, or email. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue SW., Room 509F
HHH Building, Washington, DC 20201
1-800-868-1019, 800-537-7697 (TDD).
Complaint forms are available at

The Surgery Center at United Medical Park complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Informing Individuals With Limited English Proficiency of Language Assistance Services
If you speak a foreign language, assistance services are available to you free of charge.

Specific translations for Notice of Nondiscrimination, Nondiscrimination and Taglines are available at:

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (319) 361 6699.

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-(319) 361 6699.

CHÚ Ý: Nếu bn nói Tiếng Vit, có các dch v h tr ngôn ng min phí dành cho bn. Gi s 1-(319) 361 6699.

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-(319) 361 6699.

Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-(319) 361 6699.

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 있습니다. 1-(319) 361 6699 번으로 전화해 주십시오.

ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-(319) 361 6699.

ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-913-163-9966 (رقم هاتف الصم والبكم: 1-913-163-9966.

ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-(319) 361 6699.

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-(319) 361 6699.

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-(319) 361 6699.

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer
1-(319) 361 6699.

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-(319) 361 6699.

ប្រយ័ត្ន៖ បើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, សេវាជំនួយផ្នែកភាសា ដោយមិនគិតឈ្នួល គឺអាចមានសំរាប់បំរើអ្នក។ ចូរ ទូរស័ព្ទ 1-319 361 6699

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-(319) 361 6699.

Section 1557 of the Affordable Care Act Grievance Procedure

It is the policy of The Surgery Center at United Medical Park not to discriminate on the basis of race, color, national origin, sex, age or disability. The Surgery Center has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. 18116) and its implementing regulations at 45 CFR part 92, issued by the U.S. Department of Health and Human Services. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities.

Any person who believes someone has been subjected to discrimination on the basis of race, color, national origin, sex, age or disability may file a grievance under this procedure. It is against the law for the Practice to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance.

Submission of Grievance
Grievances must be submitted to the Section 1557 Coordinator within (60 days) of the date the person filing the grievance becomes aware of the alleged discriminatory action.

A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.

The Section 1557 Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it will be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 1557 Coordinator will maintain the files and records of the Practice relating to such grievances. To the extent possible, and in accordance with applicable law, the Section 1557 Coordinator will take appropriate steps to preserve the confidentiality of files and records relating to grievances and will share them only with those who have a need to know.

The Section 1557 Coordinator will issue a written decision on the grievance, based on a preponderance of the evidence, no later than 30 days after its filing, including a notice to the complainant of their right to pursue further administrative or legal remedies.

The person filing the grievance may appeal the decision of the Section 1557 Coordinator by writing to the (Chief Executive Officer) within 15 days of receiving the Section 1557 Coordinator’s decision. The (Chief Executive Officer) shall issue a written decision in response to the appeal no later than 30 days after its filing.

The availability and use of this grievance procedure does not prevent a person from pursuing other legal or administrative remedies, including filing a complaint of discrimination on the basis of race, color, national origin, sex, age or disability in court or with the U.S. Department of Health and Human Services, Office for Civil Rights. A person can file a complaint of discrimination electronically through the Office for Civil Rights Complaint Portal, which is available at:, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201.

Complaint forms are available at: Such complaints must be filed within 180 days of the date of the alleged discrimination.

Accommodations in the Grievance Process
The Surgery Center will make appropriate arrangements to ensure that individuals with disabilities and individuals with limited English proficiency are provided auxiliary aids and services or language assistance services, respectively, if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing qualified interpreters, providing taped cassettes of material for individuals with low vision, or assuring a barrier-free location for the proceedings. The Section 1557 Coordinator will be responsible for such arrangements.


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