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Fax: 630-305-3301

CMS Advance Notification to Patients

Advance Notification to Patients

This information is being supplied to you prior to your surgery in compliance with federal regulations.  Please read it carefully; upon checking in at the reception desk on the day of surgery you will be asked to sign an acknowledgement that you received this information.

Mission Statement
To effectively provide appropriate, safe, efficient and cost-effective care to patients requiring elective ambulatory surgery.

Reporting of Complaints
If you have concerns about the quality of care and/or patient safety of this licensed ambulatory surgical treatment center, please notify any member of our staff or our Administrator.  If your concerns are not sufficiently addressed, you may also contact one of the following agencies:

File a complaint with the Illinois Department of Public Health by writing the following address:

Illinois Department of Public Health, Division of Health Facilities Standards, 525 West Jefferson Street, Springfield, IL  62761; or you may call 1-800-252-4343 during regular business hours.

Contact the Joint Commission at 1-800-994-6610, or www.jointcommission.org.  Written inquiries may be sent to Joint Commission Office of Quality Monitoring, One Renaissance Boulevard, Oakbrook Terrace, IL, 60181.

Contact the office of the Medicare Beneficiary Ombudsman at www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman/html.

Patient Bill of Rights
The staff works hard to respect and support the Rights of all patients.  These Rights are:

  • To be treated with respect, consideration, and dignity.
  • To obtain information regarding and have reasonable access to the services offered by the surgery center.
  • To obtain, to the degree known, information concerning your diagnosis, treatment, and prognosis. When concern for your health makes it inadvisable to give such information to you, it is made available to an individual designated by you or to a legally authorized individual.
  • To know the names of the surgeon, anesthesiologist and nurses responsible for your care, treatment and services.
  • To receive from your physician information necessary to give informed consent prior to the start of any procedure, including the specific procedure, the medically significant risks involved, and the probable duration of incapacitation.
  • To refuse care, treatment and services to the extent permitted by law and be informed of the medical consequences of your action.
  • To be informed, including your family when appropriate, about the outcomes of care, treatment and services, including unanticipated outcomes.
  • To be free from mental, physical, sexual and verbal abuse, neglect and exploitation.
  • To refuse the photographing or videotaping of your surgery for medical or educational purposes, or the admittance of qualified observers to the operating room.
  • To be assured of confidential treatment of disclosures and records, and be afforded the opportunity to approve or refuse the release of such information, except when release is provided by law.
  • To participate in decisions involving your health care, including the consideration of ethical issues that impact your care and resolution of conflicts about care decisions.
  • To expect and receive appropriate assessment and management of pain.
  • To have your cultural, psychosocial, spiritual and personal values respected so long as they do not harm others or interfere with medical therapy.
  • To receive treatment in a private and secure environment to the extent consistent with providing adequate medical care. This shall not preclude discreet discussion of your case or examination by appropriate health care personnel.
  • To expect reasonable continuity of care, including complete, written post surgical care instructions, and provisions for communicating with the surgery center and your surgeon after business hours should an emergency arise.
  • To be advised of fees for services, policies concerning payment of fees prior to the performance of surgery, and to examine and receive an explanation of your bill regardless of the source of payment.
  • To express complaints about the care and services provided, recommend changes in policies and services to the surgery center’s staff, the governing authority and the Illinois Department of Public Health, and have the surgery center investigate such complaints, without fear of reprisal.
  • To obtain information as to any relationship of the surgery center to other health care institutions insofar as your care is concerned, and obtain information as to the existence of any professional relationships among individuals, by name, who are treating you.

Patient Responsibilities
Patients’ responsibilities include:

  • Providing complete medical information, including but not limited to, current medical conditions, past medical history, past surgeries, current medications and supplements, allergies, pertinent family history, disabilities or impairments requiring assistance;
  • Accepting the consequences of not providing complete medical information or following care related instructions;
  • Complying with pre-operative, intra-operative and post-operative care related instructions;
  • Complying with any required pre-op testing and evaluation requirements;
  • Participating in your care plan as needed;
  • Making arrangements for a companion and transportation as required by center policy;
  • Questioning staff regarding anything you do not understand or need clarification on;
  • Following the rules and regulations of the surgery center;
  • Showing respect and consideration for staff and fellow patients;
  • Providing complete insurance information;
  • Complying with insurance requirements such as obtaining referrals and precertifying necessary services prior to day of surgery;
  • Meeting your financial commitments in paying any required co-payment, deductible and balance remaining;
  • Facilitating reimbursement of your claim from the insurance company if needed;
  • Refraining from smoking in the surgery center;
  • Completing the patient satisfaction survey.

Patient Safety Tips
We are working to make health care safety a priority. You, as the patient, can also play a role in making your care safe by becoming an active, involved and informed member of your health care team.

While you are a patient at the surgery center we want you to feel comfortable to do the following:

  • Expect our nursing staff to introduce themselves when they enter your room, and look for their name tags.
  • Ask about the purpose of medications you are given, including possible side effects. Make sure you can read the handwriting on any prescriptions written by your doctor. Don’t be afraid to tell the nurse or the doctor if you think you are about to receive the wrong medication.
  • Don’t hesitate to tell a member of our staff if you think he or she has confused you with another patient.
  • Expect our clinical staff to have washed their hands.
  • Make sure your nurse or doctor confirms your identity, that is, checks your wristband and asks your name, before he or she administers any medication or treatment.
  • Educate yourself about your diagnosis and planned surgical procedure.
  • Thoroughly read all forms and the consent for surgery and make sure you understand them before signing. If you don’t understand, ask our staff or your doctor to explain them.
  • Expect your doctor and/or nurse, with your participation, to mark the area that is to be operated upon. Since marking is not feasible or required for all procedures, ask your doctor or nurse if you are unsure if it is necessary.
  • Before you leave our facility, be sure that you understand all the post-operative instructions.
  • Consider asking your companion to ask questions that you may not think of, to help remember answers to questions you have asked, and to speak up for you if you cannot.
  • Make sure your companion understands the type of care you will need when you get home. Your companion should know what to look for if your condition gets worse and whom to call for help.
  • Speak up if you have questions or concerns, and if you don’t understand, ask again. Don’t be afraid to ask about safety.  Tell your nurse or doctor if something doesn’t seem quite right.
  • Participate in all decisions about your treatment.

Surgery Center Ownership
This surgery center is owned by the following entities:

DuPage Medical Group

Surgical Care Affiliates, Inc.

Advocate Network Services

You may ask your physician/surgeon for further details on surgery center ownership.  You may also request your surgery be scheduled at another facility at which your physician/surgeon holds medical staff membership.

Advance Directives
For the purposes of this disclosure, “advance directive” means written instructions, such as a living will or durable power of attorney for healthcare, recognized under Illinois law and relating to the provision of healthcare when the individual is terminally ill or incapacitated and unable to communicate his/her desires.  All patients have the right to participate in their own health care decision and to make Advanced Directives or to execute Powers of Attorney that authorized others to make decisions on their behalf based on the patient’s expressed wishes when the patient is unable to make decisions or unable to communicate decisions.  This Surgery Center respects and upholds those rights.  However, unlike in an Acute Care Hospital setting, the Surgery Center does not routinely perform “high risk” procedures.  Most procedures performed in this facility are considered to be of minimal risk.  Of course, no surgery is without risk.  You will discuss the specifics of your procedure with your physician who can answer your questions as to its risks, your expected recovery and care after your surgery.   Therefore, it is our policy, regardless of the contents of any Advance Directive or instructions from a health care surrogate or attorney in fact, that if an adverse event occurs during your treatment at this facility, we will always attempt to resuscitate, use stabilizing measures, and transfer you to an Acute Care Hospital for further evaluation.  At the Acute Care Hospital, further treatment or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, Advance Directive or Health Care Power of Attorney.  If you do not agree to this policy, we are pleased to assist you to reschedule the procedure.

If you desire assistance regarding the preparation of advance directives, you can obtain information from the following sources:

Your attorney

Your physician


The Illinois Department on Aging

421 East Capitol Avenue

Springfield, Illinois  62701

1-800-252-8966 for free living will/power of attorney forms


American Medical Association

PO Box 109050

Chicago, Illinois  60610

1-800-621-8335, Order #NC634492 for free brochure


Legal Counsel for Elderly Persons

601 East Street NW

Washington, DC  20049



Choice in Dying

PO Box 397

Newark, New Jersey 07101-9792

800-989-WILL or 212-366-5540

American Association for Retired Persons (AARP)



Revised 8/18/16