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515 Pacific Avenue Audubon, IA 50025

Phone: (712) 563-2611

To Schedule An Appointment with a Specialist

Call 712.563.5304

MENUMENU
  • About
    • Board of Trustees
    • Administration
    • Careers
    • Contact
    • History
  • Services
    • Cardiac Rehabilitation
    • Emergency
    • Infusions
    • Laboratory
    • Medical Surgical Unit
    • Outpatient Specialty Clinic
    • Radiology
    • Rehabilitation Services
      • Sleep Studies
    • Respiratory Therapy
    • Skilled Care
    • Surgery
    • Telemedicine Services
  • Providers
    • Specialists
    • Jeff Maire, DO
    • Stephanie Vampola, DO
    • Nicole (Colee) Hayworth, DNP, CRNA, ARNP- Anesthesia
    • Vivian Chance, ARNP
    • Kelli Borkowski, ARNP
    • Rae McDivitt, ARNP
    • Valerie Riesberg, ARNP
    • Jackie Wilson, ARNP
    • Brittany Bremser, ARNP/ER/FP
  • Clinics
    • Audubon Family Health Care
    • Exira Medical Clinic
    • Outpatient Specialty Clinic
    • New Patient Forms
  • Patients
    • Accessing Health Information
    • Advance Directives
    • Community Health Needs Assessment
    • Financial Assistance
    • Get Directions
    • Insurance & Your Bill
    • News & Events
    • No Surprises Act
    • Nondiscrimination Notice
    • Notice of Privacy Practices
    • Patient Portal
    • Patient Rights & Responsibilities
    • Pay My Bill Online
    • Price Transparency
    • Immunization Schedules
    • Resources
    • COVID Info
  • Foundation
    • Foundation Board
    • Foundation Events
    • Ways to Give
  • Pay My Bill Online
  • Access Patient Portal
  • Get Directions
  • Apply for a Career
  • Telemedicine Services

New Patient Forms

 

515 Pacific Avenue
Audubon, IA 50025
Phone: (712) 563-2611

If you speak another language, assistance services, free of charge, are available to you in person coordinated by a staff member.

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Contact Us

Call 712.563.2611

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 http://www.ascr.usda.gov/complaint_filing_cust.html, 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.