We’re a charitable organization that provides financial assistance to those who are eligible. Some of our options include payment plans, financial counselors and discounts for self-pay patients and those who are uninsured. The Day Surgery Center is a for-profit organization, which also provides financial assistance to those who are eligible.
Please print the Financial Assistance Application below and complete all the necessary fields. Also, be sure to include all the requested documentation so that we can process your application as quickly as possible. If you need assistance, financial counselors are available by phone at 847-618-4542, Monday–Friday: 8:00 am–5:00 pm. Or, they can meet with you in person at our Financial Counseling and Medical Records Center, Monday–Friday: 8:00 am–5:00 pm and in the Emergency Department daily: 5:00 pm–9:00 pm.
Select a form and your preferred language to continue
Financial Assistance Application and Cover Letter
Policy Appendices and Forms
Financial Assistance Plain Language Summary
Financial Assistance Policy
Our counselors can answer questions about your medical expenses and payment options. They can also discuss estimates for procedures, help you make payments, collect self-pay balances prior to services/admission, set up payment plans and help with completing applications for financial assistance for medical bills.
In addition, our financial counselors will review payment and funding options that may be available to you, including applications for Illinois Medicaid, All Kids or Family Care programs, Illinois Violent Crime Victims Assistance Fund, other government-sponsored plans, grants, community funding, financial assistance and/or charity care.