Patient Info

Privacy Policy


We are required by federal law to maintain the privacy of your medical information and to give you our Notice of Privacy Practices (this "Notice") that describes our privacy practices, our legal duties and your rights concerning your medical information.

This is required privacy Notice of the Quad City Ambulatory Surgery Center (the "Facility") and its organized health care arrangement. This Notice applies to and will be followed by: (1) all employees, staff, volunteers and other personnel of the Facility, and (2) the physicians and other practitioners who are not employed by the Facility, but who have privileges to treat patients at the Facility, and who are members of the Facility's organized health care arrangement (see description of the Facility's organized health care arrangement, below)

How We May Use And Disclose Your Medical Information
The Facility is permitted or required to use or disclose your medical information without your authorization (permission) in the following situations. Some, but not all, specific examples of the different types of disclosures have been listed.

TREATMENT. To provide you with medical treatment or services (e.g., provide information to doctors, nurses, technicians, students or other personnel who are involved in your care).

PAYMENT. To collect payment from you, an insurance company or a third party for the treatment and services you receive (e.g., submitting a claim to your insurance company).

HEALTH CARE OPERATIONS. Health care operations are the uses and disclosures of information that are necessary to run the surgery center and to make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services, and to evaluate the performance of our staff and physicians in caring for you. We may use your name and address to send you a newsletter or a patient satisfaction survey. We will get your written consent before making disclosures to others outside the facility for health care operations purposes.

APPOINTMENTS AND HEALTH CARE SERVICES. To provide you with appointment reminders or to notify you of possible treatment alternatives or health-related benefits or services.

FACILITY DIRECTORY. While you are a patient, your name, location in the Facility, general condition (e.g., fair, serious, etc.), may be given to friends, family, or a member of the clergy. You have the right to request that your name not be included in the directory.

FRIENDS AND FAMILY. To a friend or a family member involved in your medical care or payment for your care. If you are available, such disclosures will be made only if we have obtained your permission, if you do not object to the disclosure after having the opportunity, or if it is reasonable to us, based on the circumstances, to assume you have no objection to such disclosure. If you are unavailable, incapacitated or in an emergency situation, the Facility may disclose limited information to these persons if the Facility determines disclosure is in your best interest.

HEATH CARE PROVIDERS. To another health care provider involved in your treatment in order for that provider to treat you, bill for services and conduct its health care operations.

DISASTER RELIEF. To a public or private entity assisting in a disaster relief effort (e.g., to notify your family about your location, condition or death).

PUBLIC HEALTH ACTIVITIES. To public health authorities for public health activities as permitted or required by law (e.g., to report births, deaths, child abuse and neglect, immunizations and communicable diseases).

ABUSE, NEGLECT AND DOMESTIC VIOLENCE. The Facility may notify the appropriate government authority if it believes that you have been the victim of abuse, neglect or domestic violence. Unless such disclosure is required by law, the Facility will only make this disclosure if you agree or under other limited circumstances when such disclosure is authorized by law.

HEALTH SAFETY RISKS. Under certain circumstances, when necessary to prevent a serious threat to your health and safety or to the health and safety of the public or another person.

ORGAN DONATIONS. To organ procurement or organ, eye or tissue transplantation organizations, or to organ donation banks to facilitate organ or tissue donation and transplantation.

MILITARY AND NATIONAL SECURITY. If you are a member of the armed forces, as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. The Facility may also release your medical information to authorized federal officials for intelligence, counterintelligence, and other authorized national security activities.

WORKER'S COMPENSATION. To persons (e.g., employers, insurance carriers, attorneys) in order to comply with workers' compensation laws or other similar programs providing benefits for work-related injuries.

HEALTH OVERSIGHT ACTIVITIES. To a health oversight agency for activities authorized by law to monitor the health care system, government programs and compliance with civil rights laws (e.g., fraud and abuse investigations, inspections and licensure, or disciplinary actions).

LEGAL PROCEEDINGS. If you are involved in a lawsuit or dispute, in response to a court or administrative order. The Facility may also disclose medical information about you in response to subpoena or other lawful process by someone else involved in the dispute, but only if the party seeking the information demonstrates that reasonable efforts have been made to notify you of the request or to obtain a protective order from court.

LAW ENFORCEMENT. To law enforcement authorities for law enforcement purposes, such as (1) in response to a court order, subpoena, warrant, summons or similar process, (2) identify or locate suspect, fugitive, material witness or missing person, (3) if you are a victim of a crime, but only if your agreement is obtained or, under certain limited circumstances, if the Facility premises, and (6) in emergency circumstances, to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. The Facility must comply with federal and state laws in making such disclosures.

DECEASED INDIVIDUALS. To a coroner or medical examiner (e.g., to identify a deceased person or determine the cause of death), or to funeral directors as necessary to carry out their duties.

CORRECTIONAL INSTITUTIONS. To a correctional institution where you are an inmate or to law enforcement official who has custody of you for certain limited purposes (e.g., to provide you with health care).

RESEARCH. Federal law permits the surgery center to use and disclose medical information about you for research purposes, either with your specific, written authorization or when the study has been reviewed for privacy protection by an Institutional Review Board or Privacy Board before the research begins.

LIMITED MEDICAL INFORMATION. Limited medical information to a third party for research purposes, public health activities and Facility health care operations. The party to whom we disclose the information is requires to keep it confidential.

REQUIRED BY LAW. When required to do so by federal, state or local law (e.g., to report child or dependent adult abuse and violent wounds).

INCIDENTAL DISCLOSURES. Occasional incidental, unintended disclosures of your medical information which might occur during a permitted use or disclosure (e.g., information overheard during a discussion regarding your care with you or a member of your family). We will take reasonable steps to avoid these types of disclosures.

BUSINESS ASSOCIATES. Some of the activities described above are performed through contracts with outside persons or organizations ("business associates"), such as legal services. It may be necessary for the Facility to provide some of your medical information to outside business associates who assist the Facility with these activities. The Facility requires that its business associates appropriately safeguard the privacy of your information.

ORGANIZED HEALTH CARE ARRANGEMENT. The Facility is a clinically integrated care setting where patients receive care from Facility personnel and from independent doctors and other practitioners who provide care to patients at the Facility (collectively called "practitioners"). The Facility and these practitioners need to share medical information freely to provide care to patients, and to conduct Facility health care operations. Therefore, the Facility and the practitioners have agreed to follow uniform information practices when using or disclosing medical information related to inpatient or outpatient hospital services. This arrangement is called an "organized health care arrangement" and only covers information practices for services rendered through the Facility.

It does not cover the information practices of the practitioners in their offices or at other care settings. It does not alter the independent status of the Facility and the practitioners or make them jointly responsible for the clinical services provided to them. In other words, the Facility is not responsible for (1) the negligence (or mistakes) of the independent practitioners providing care at the Facility; or (2) any violations of your privacy rights by the independent practitioners.

YOU AND YOUR AUTHORIZATION. Uses and disclosures medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you give us permission to use or disclose medical information about you, you may revoke (take back) that permission, we will no longer use or disclose medical information about you for the reasons set forth in your written authorization. We are unable to take back any disclosures we have already made with your permission.


Your Rights

ACCESS TO MEDICAL INFORMATION. You may request to inspect and copy much of the medical information we maintain about you, with some exceptions. This includes most medical and billing records. Your request must be in writing. We may charge a fee for the cost of copying, mailing, and other supplies associated with your request.

REQUEST FOR RESTRICTIONS. You have the right to request a restriction on how we use or disclose your medical information for treatment, payment, or health care operations, or to certain family members or friends identified by you who are involved in your care or the payment for your care.

You must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, if you want to prohibit disclosures to your spouse. We are not required to agree to your request, but will notify you if we are unable to agree.

AMENDMENT. You may request that we change part of your medical information if you believe that it is incorrect or incomplete. You must provide a reason that supports your request. We are not required to make all requested amendments, but we will give each request careful consideration. If we deny your request, we will provide you with written explanation of the reasons and your rights.

ACCOUNTING. You have the right to receive a list of certain disclosures of your medical information made by us or our business associates. You must state a time period for your request, which may not be longer than six years and may not include dates before April 14, 2003. The first list in any 12-month period will be provided to you for free; you may be charged a fee for each subsequent list you request within the same 12-month period.

CONFIDENTIAL COMMUNICATIONS. You have the right to request that we communicate with you about medical matters in a certain location. For example, you can ask that we contact you only at work or only by mail. Your request must specify how or where you wish to be contacted, and we may require you to provide information about how payment will be handled. We will agree to your request if it is reasonable.

PAPER NOTICE. You have the right to receive paper copy of this notice. You may ask us to give you a copy of this Notice any time.

HOW TO EXERCISE THESE RIGHTS. All requests to exercise your privacy rights must be in writing. We will follow written policies to handle requests, and we will notify you of our decision or actions and your rights. Contact the Privacy Officer at the contact information at the end of this Notice or to obtain request forms.

COMPLAINTS. If you believe your privacy rights have been violated, you may file a complaint with the Facility using the contact information at the end of this Notice. You may also submit a complaint with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or retaliated against for filing a complaint.

QUESTIONS. If you have questions about this Notice, please contact the Privacy Officer or the Administrative Director of the Center at the telephone number listed.

About This Notice
The Facility is required to abide by the terms of the Notice currently in effect. The Facility reserves the right to change terms of this Notice and make the new Notice provisions effective for all of your medical information that it maintains, including that which it created or received while prior Notice was in effect. If the Facility makes a material change to its privacy practices, it will amend its Notice. We will post a copy of the current Notice in the Facility. The Notice will state the effective date.

Patient Rights & Responsibilities

At the Quad City Ambulatory Surgery Center we understand that health care involves a partnership between patients, families, and health care providers, each of whom have certain rights and responsibilities. We want you to be well informed, participate in treatment decisions, and communicate openly with your doctors and health care providers. We encourage respect for personal preferences and values of each individual.

While at the Quad City Ambulatory Surgery Center, you have the right to...

Considerate and respectful care based on the psychosocial, spiritual and cultural needs of you and your family.

Treatment without regard to race, color, creed, national origin, disability, veteran status, sex or age.

Privacy. Your doctor, and the health care providers at the Quad City Ambulatory Surgery Center will protect your privacy as much as possible.

Health care professional credentialing documents.

Be well informed about your treatment and request information related to specific procedures and treatment, the risks involved, length of procedure and recuperation, reasonable alternatives and their accompanying risks and benefits.

Know the names and roles of the people taking care of you.

Know the financial implications, both immediate and long term; including fees for service, policies and procedures for billing insurance, collecting co-pays and deductibles, and procedure for cash payments.

Receive appropriate pain management for post operative pain.

Make decisions about your plan of care, prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and the Quad City Ambulatory Surgery Center policy, and to be informed of the consequences of this action.

Expect that treatment records are confidential unless you have given permission to release information or reporting is required or permitted by law. When we release records to others, such as insurers, it emphasizes that the records are confidential.

Review your medical records and to have the information explained, except when restricted by law.

Know if the Quad City Ambulatory Surgery Center has relationships with outside parties.

Consent or decline to take part in research affecting your care. If you choose not to take part, you will receive the most effective treatment that your physician and surgery center have to offer.

Know that marketing regarding the competency and capabilities of your physicians is not misleading.

Know that you may change specialty physicians if other qualified physicians are available.

As a patient, you are responsible for...

Providing information about your health, including past and present illnesses, hospital stays, and use of medication.

Expressing any concerns regarding your ability to comply with recovery care plan. Every effort will be made to meet your specific needs and limitations.

Be respectful of all health care providers and staff, as well as other patients and visitors.

Providing a copy of your Advance Directive. If you have a living will, Durable Power of Attorney, please provide a copy to our staff.

Asking questions when you do not understand information or instructions. SPEAK UP!

Telling us about your pain. Tell your physician or nurse if your pain medication does not reduce or relieve your pain.

Reporting unexpected changes in your condition to the health care provider responsible for your care.

Following the plan of care. The nurse, upon discharge, will provide instructions from your physician, for recovery. There may be a need to involve family as there are times that they play an important role in this plan.

We look on feedback, both positive and negative, as an opportunity to continuously improve our service. If you wish to discuss the care and/or service you received while a patient here, please ask the nurse taking care of you to speak to the Administrative Director or the substitute person assigned to answer grievances.

Medicare Ombudsman

Advance Directives

The Quad City Ambulatory Surgery Center supports the patient’s rights to make legally valid informed decisions about future medical treatment. We have a formal process that is established to inform patients of their rights to direct their own medical care and to inform health care personnel regarding the utilization of advance directives. In the ambulatory care setting, if a patient should suffer a cardiac or respiratory arrest or other life-threatening situation, the signed consent implies consent for resuscitation and transfer to a higher level of care.

Therefore, in accordance to federal and state law, the Quad City Ambulatory Surgery Center will not honor previously signed Advance Directives for any patient.

Patients must be aware that previously signed Advanced Directives will not be honored at the Center.

If you have an Advanced Directive, federal regulations require that a copy be available. Please bring that on the day of surgery.

If you would like more information regarding Advance Directive, we have packets available, both for Iowa and Illinois.

We also have information about Choices Connection, a comprehensive advanced care planning service intended to help you and your loved ones. Whether you live in Iowa or Illinois, this no-cost service provides a trained volunteer to talk to you about choices you need to make.

If you wish to contact Choices Connection directly:
(563) 324-9085
or toll free:
(800) 892-9085
or by mail at:
935 E. 53rd Street
Davenport, IA 52807

Grievance Policy

We look on feedback, both positive and negative, as an opportunity to continuously improve our service. If you wish to discuss the care and/or service you received while a patient here, please ask the nurse taking care of you to speak to the Administrative Director or the substitute person assigned to answer grievances.

Illinois Department of Public Health - Complaint Registry
Or Mail to:
The Illinois Department of Health
525 West Jefferson St
Springfield, IL 62761

The investigation/resolution will be reported back to the patient within 10 working days.

Iowa Department of Inspection and Appeals

Medicare Ombudsman