Illinois Ambulatory Surgery Center AssociationIASCA

Membership Application

Membership Category

Membership is available for ASCs licensed in the state of Illinois. Please send proof of license with your application.

ASC Information

  • (the legal name of your ASC)
  • (please include all nine digits)

Facility Staff

  • (This individual will be listed as the contact to receive annual dues invoices)

Additional Facility Information

Please Check ALL (Check all that apply)

Please Check ALL (Check all that apply)

Payment Information (must be made in U.S. dollars)

  • Billing Information

If paying by check, make check payable to: IASCA

Mail payment to:
Illinois Ambulatory Surgery Center Association
Two Woodfield Lake
1100 E. Woodfield Road, Suite 350
Schaumburg, IL 60173

  • If accepted for membership, I hereby agree to abide by the Constitution and Bylaws of the Illinois Ambulatory Surgery Center Association.
  • 805312