• 1N141 County Farm Road
  • Suite 130
  • Winfield, Illinois 60190
  • Phone: (630) 752-9725
  • Fax: (630) 752-9726
  • Email
Privacy Policy

Privacy Policy

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your medical information is important to us.

Our Legal Duty

Nickerson & Associates, P.C. is required by federal and state law to maintain the privacy of your medical information. It is also required to provide you with this notice about our privacy practices, our legal duties, and your rights concerning your medical information.

This notice takes effect April 14, 2003 and will remain in effect until it is revised and/or updated.

Nickerson & Associates, P.C. provides its Notice of Privacy Practices to every patient with whom it has a direct treatment relationship. The Notice is provided no later than the date of first treatment to patients after April 13, 2003. When a direct treatment patient receives the Notice, we ask patients to sign its “Consent for Release and Use of Confidential Information and Receipt of Notice of Privacy Practices” form. You may request a copy of this notice at any time.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted under law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all medical information that we maintain, including medical information we created or received before we made the changes.

When changes are made to the notice, the updated document will be available to you upon request.

Using and Disclosing Your Medical Information

Nickerson & Associates, P.C. reasonably ensures that the protected health information (PHI) it requests, uses and discloses for any purpose is the minimum amount of PHI necessary for that purpose.

Nickerson & Associates, P.C. makes reasonable efforts to ensure that PHI is only used by and disclosed to individuals that have a right to protected health information. Toward that end, we make reasonable efforts to verify the identity of those using or receiving PHI.

We must disclose your medical information to you, as described in the Individual Rights section of this notice. We may disclose your medical information to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care, but only if you agree that we may do so.

We use and disclose medical information about you for treatment, payment, and health care operations. For example:

Treatment could include consulting with or referring your case to another health care provider such as a physician, psychologist, therapist, clinic or hospital. The type of health information that could be used or disclosed includes: medical history, diagnoses, medications or care plan pertinent to your care.

Payment means we may use and disclose your medical information to obtain payment for services provided to you.

Health care operations could include activities such as quality improvement activities, audits of billing processes, and reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Uses or Disclosures We May Make Without Your Authorization

Uses and Disclosures Required by Law: Nickerson & Associates, P.C. uses and discloses protected health information to appropriate individuals as required by law.

The practice discloses protected health information regarding victims of abuse, neglect, or domestic violence. The practice discloses information about a minor, disabled adult, nursing home resident, or person over 60 years of age whom the practice reasonably believes to be a victim of abuse or neglect to the appropriate authorities as required by law or, if not required by law, if the individual agrees to the disclosure. This includes child abuse and neglect, elder abuse and exploitation, abused and neglected nursing home residents, or disabled adults abuse.

The practice informs the individual of the reporting unless the practice, in the exercise of professional judgment, believes informing the individual would place the individual at risk of serious harm or the practice would be informing a personal representative, and the practice believes the personal representative is responsible for the abuse, neglect, or other injury, and that informing such person would not be in the best interests of the individual as determined by the professional judgment of the practice.

We may also use and disclose medical information in the following manner:

  • We may disclose your medical information in response to a court or administrative order, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant or grand jury subpoena, we may disclose your medical information to law enforcement officials.
  • We may use or disclose your medical information when we are required to do so by federal, state or other applicable law. We may disclose your medical information when authorized by workers’ compensation or similar laws.
  • We may disclose protected health information for military and veterans activities, national security and intelligence activities and other activities as required by law.
  • We will not use or disclose your medical information if it is prohibited or materially limited by other applicable law including, but not limited to, the Illinois Nursing Home Care Act; Illinois Medical Practice Act; Illinois Mental Health and Developmental Disabilities Code; Illinois AIDS Confidentiality Act; Illinois Mental Health and Developmental Disabilities Confidentiality Act; and the Federal Drug Abuse, Prevention, Treatment and Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970.

More Stringent Protection For Your Health Information

In certain cases, Illinois law provides more stringent privacy protections of your health information than this Privacy Notice recites.

If you are an unemancipated minor under Illinois law, then we will not disclose, without your authorization, information related to your care regarding treatment abuse of drugs or alcohol or emotional disturbance to a parent, legal guardian, person standing in loco parentis or a legal custodian who has legal authority to provide permission for your medical or psychiatric care.

Psychotherapy Notes

Psychotherapy notes may be disclosed by your therapist only after you have given written authorization to do so. Limited exceptions exist, e.g. to prevent you from harming yourself or others and to report abuse/neglect. All records kept at Nickerson & Associates, P.C. are considered psychotherapy notes. You cannot be required to authorize the release of your psychotherapy records in order to obtain health-insurance benefits for your treatment, or enroll in a health plan. You do not have the right to review or receive a copy of psychotherapy notes without the consent of the provider.

No Other Uses or Disclosures Without Your Written Authorization

We will not make any other uses and disclosures of your individually identifiable health information without your written authorization. Illinois state law requires a specific written authorization to disclose or release mental health, alcoholism treatment information. Your authorization may be revoked at any time if you provide written notice to us.

Individual Rights

You may request to review or receive a copy of your medical information, with limited exceptions. If we are unable to satisfy your request, we will tell you in writing the reason for the denial and your right, if any, to request a review of the decision. If you request copies, there may be a charge of Illinois law prohibits charges that exceed the following: $20.48 handling fee plus 77 cents each for pages 1-25, 51 cents each for pages 26-50, and 26 cents each for pages 51 to end. The practice limits charges for records to the amounts allowed under Illinois law.

You have the right to receive a list of instances in which we or our business associates disclosed your medical information for purposes, other than treatment, payment, health care operations and certain other activities since April 14, 2003. We will provide you with the date on which we made the disclosure, the name of the person or entity to whom we disclosed your medical information, a description of the medical information we disclosed, the reason for the disclosure, and certain other information.

You have the right to request that we place restrictions on our use or disclosure of your medical information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf.

You have the right to request that we communicate with you about your medical information by alternative means or to alternative locations. You must make your request in writing. We will accommodate your request if it is reasonable, specifies the alternative means or location, and provides satisfactory explanation how payments will be handled under the alternative means or location you request.

You have the right to request that we amend your medical information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request if we did not create the information you want amended or for certain other reasons.

The practice never requires an individual to waive any of his or her individual rights as a condition for the provision of treatment, except under very limited circumstances allowed under the law.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your medical information or in response to a request you made to amend or restrict the use or disclosure of your medical information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. Office for Civil Rights, U.S. Department of Health and Human Services, 233 N. Michigan Ave., Suite 240, Chicago, Ill. 60601, Voice Phone (312) 886-2359, FAX (312)886-1807, TDD (312)353-5693.

We support your right to protect the privacy of your medical information. We will not take any adverse action against any patient if you choose to file a complaint with us or with the U. S. Department of Health and Human Services.

Contact: Privacy Officer – Nickerson & Associates, P.C.
Telephone: 630-752-9725
Fax: 630-752-9726
Address: PO Box 239, Winfield, IL 60190


Nickerson & Associates, P.C. reserves the right to amend the terms of this Privacy Notice at any time and to apply the revised Privacy Notice to all individually identifiable health information that it maintains. If Nickerson & Associates, P.C. amends this Privacy Notice, you will be provided with a revised copy at your next visit, or upon request.