Patient Rights & Responsibilities

Rockford Ambulatory Surgery Center views health care as a partnership between you and your caregivers. We respect your rights, values and dignity. We also ask that you recognize the responsibilities that come with being a patient, both for your own well-being and that of your fellow patients and caregivers. Please read and exercise these rights and responsibilities as outlined here. Should you or your designated guardian, surrogate, or representative feel your rights as a Surgery Center patient have been violated, please contact our Administrator at 815-226-3300.


  • You have the right to safe, high quality, medical care, without discrimination, that is compassionate and respects personal dignity, values and beliefs.
  • You have the right to participate and make decisions about your care and pain management, including refusing care to the extent permitted by law. Your care provider (doctor, nurse, etc.) will explain the medical consequences of refusing recommended treatment.
  • You have the right to have your illness, treatment, pain, alternatives and outcomes be explained in a manner you can understand. You have the right to interpretation services if needed.
  • You have the right to know the name and role of your care providers (doctor, nurse, etc.).
  • You have the right to request that a family member, friend and/or physician be notified that you are under the care of this facility.
  • You have the right to be informed about transfers to another facility or organization, and be provided complete explanation including alternatives to a transfer.
  • You will receive information about continuing your health care at the end of your visit.
  • You have the right to know the policies that affect your care and treatment.
  • You have the right to change providers if other qualified providers are available.
  • You have the right to private and confidential treatments, communications and medical records permitted by law.
  • You have the right to access your medical records in a reasonable timeframe, to the extent permitted by law.
  • You have the right to be informed of charges for services and receive financial counseling on the availability of financial arrangements for health care.
  • You and your family have the right to have your compliments, concerns and grievances addressed. Sharing your concerns and complaints will not compromise your access to care, treatment and services.

Grievances may be filed with the following agencies:

Illinois Department of Public Health
Central Complaint Registry
525 W. Jefferson Street
Springfield, IL 62761

Medicare Ombudsman
Office of the Regional Administrator
233 North Michigan Avenue, Suite 600
Chicago, IL 60601


  • You are responsible for providing information about your health, medical history, medications including over the counter products and dietary supplements, allergies, sensitivities and insurance benefits.
  • You are responsible for asking the care provider when you do not understand instructions about your plan of care.
  • You are responsible for following your plan of care. If you are unable or unwilling to follow the plan of care, you are responsible for telling your care provider. Your care provider will explain the medical consequences of not following the recommended treatment. You are responsible for the outcomes of not following your plan of care.
  • You are responsible for following the facility’s rules and regulations.
  • You are responsible for acting in a manner that is respectful of other patients, staff and facility property.
  • You are responsible for meeting your financial obligation to the facility.


  • An Advance Directive is a set of instructions you give about the health care you want, in the event you lose the ability to make decisions for yourself. An Advance Directive includes a Living Will, a Health Care Power of Attorney, and a DNR (Do Not Resuscitate), which allows you to refuse CPR in the event your heart and breathing stop.
  • The website to access standardized forms in the state of Illinois for a Living Will, Illinois Power of Attorney for Health Care, and for DNR Advance Directive is
  • If you would like to have a copy of one or all of the forms, a nurse may provide you with them.
  • If you have a Living Will or have an “agent” appointed to be your Health Care Power of Attorney, it is the policy of Rockford Ambulatory Surgery Center to incorporate these documents into your patient record. It is our policy that if an adverse event occurs during your treatment, the medical team will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation. A copy of your Advance Directive and/or Health Care Power of Attorney will be sent with your medical records.


English: Rockford Ambulatory Surgery Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Spanish: Rockford Ambulatory Surgery Center cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

Polish: Rockford Ambulatory Surgery Center postępuje zgodnie z obowiązującymi federalnymi prawami obywatelskimi i nie dopuszcza się dyskryminacji ze względu na rasę, kolor skóry, pochodzenie, wiek, niepełnosprawność bądź płeć.

If you would like a copy of our PATIENT RIGHTS AND RESPONSIBILITIES, please ask our receptionist or nurse

Thank you,

Rockford Ambulatory Surgery Center