Notice of Privacy Practices

Effective Date



If you have any questions about this notice, please contact our practice Privacy Officer.

This Notice of Privacy Practices describes the ways we may use and disclose medical information that identifies you (“Protected Medical Information” or “PHI”). The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates that we make this notice accessible to every patient before rendering treatment. Except for the purposes described below, we will use and disclose PHI only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer (contact information at the end of this Notice).

We are required by law to:

  • Maintain the privacy of protected health information
  • Give you this notice of our legal duties and privacy practices regarding health information about you
  • Follow the terms of our notice that is currently in effect

This Notice describes the Privacy Practices followed by the employees of Internal Medicine Associates, S.C. This includes our Physicians, Physician Assistants, nursing staff, business office and ancillary personnel.

We may use and disclose your PHI for your treatment and to provide you with treatment-related health care services. We may disclose your PHI to doctors, nurses, technicians, office staff or other personnel, including people outside our office, who are involved in your health care and need the information to provide you with medical care. This may include referring physicians.

We may use and disclose your PHI with your insurance plan or others who help pay for your care.

For example, we may give your health plan information about you so that they will pay for your treatment.

Health Care Operations
We may use and disclose your PHI for health care operation purposes. These uses and disclosures are necessary in order to improve our efficiency and quality of care and to operate and manage our office.

For example, we may use your PHI to evaluate the performance of our staff in managing patients. We also may share information with other entities that have a relationship with you (for example your health plan) for their health care operation activities.

Appointment Reminders, Referral Authorizations, And Prescription Refills
We may use and disclose your PHI to contact you to remind you of your appointments, to let you know the status of pending referral authorizations, and to let you know the status of your prescription refill requests.

Treatment Alternatives
We may use and disclose your PHI to tell you about different types of treatment available to you.

Health-Related Products And Services
We may use and disclose your PHI to tell you about health-related products or services which may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care
Unless you ask us not to, we may share your PHI with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort. If you are not present or able to say no, we may use our judgment to decide if sharing your information is in your best interest.

Under certain circumstances, we may use and disclose your PHI for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose your PHI for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any PHI.

Right Of Refusal
You must notify us in writing if you do not wish to be contacted about appointment reminders, referral authorizations, or prescription refills, and if you do not wish to receive communications about treatment alternatives or health-related products and services. Please send all such correspondence to our Privacy Officer; upon receipt, we will not use or disclose your PHI for these purposes. Your revocation will be effective when we receive it, but it will not apply to any uses or disclosures that occurred before that time.

We may also use or disclose your PHI without your permission for the following purposes, subject to all applicable legal requirements and limitations:

To Prevent A Serious Threat To Health Or Safety
We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety, or to the health and safety of the public or another person.

As Required By Law
We will disclose your PHI when required to do so by federal, state or local law.

Business Associates
We may disclose your PHI to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our agreement with such associates.

Organ And Tissue Donations
If you are an organ donor, we may use or release your PHI to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.

Military and Veterans,
If you are or were a member of the armed forces, we may release your PHI as required by military command activities. We may also release your PHI to the appropriate foreign military authorities if you are a member of a foreign military.

Workers' Compensation Cases
We may release your PHI to Workers' Compensation or similar programs. These programs provide benefits for work-related injuries and illnesses.

For Public Health Risks
We may disclose your PHI for public health reasons in order to prevent or control disease, injury or disability, or to report deaths, suspected abuse or neglect, non-accidental physical injuries, adverse reactions to immunizations or medications, or problems related to the use of specific health care products.

Health Oversight Activities
We may disclose your PHI to a health oversight agency for activities authorized by law. These activities include, for example, audits, investigations, inspections, and licensing. These activities are necessary for state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes
If you are involved in a lawsuit or a legal dispute, we may disclose your PHI in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose your PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

Law Enforcement
We may release your PHI if requested by law enforcement officials if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners And Funeral Directors
We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also release your PHI to funeral directors as necessary for their duties.

Data Breach Notification Purposes
We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your health information.

National Security
We may release your PHI with the proper federal officers for national security reasons.


The following uses and disclosures of your PHI will be made only with your written authorization:

  1. Uses and disclosures of PHI for marketing purposes; and
  2. Disclosures that constitute a sale of your PHI.
  3. In Illinois, a specific written authorization is required to disclose or release PHI regarding mental health treatment, alcoholism treatment, drug abuse treatment, or HIV/Acquired Immune Deficiency (AIDS) information except in certain limited circumstances.

Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose your PHI under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

Your Right To Inspect And Copy
You have the right to inspect and receive a copy of your PHI, including medical and billing records, that may be used to make decisions about your health care or payment for your care. You must submit a written request to our Privacy Officer in order to inspect and/or receive a copy of your health information.

If you request a copy of such information, we may charge a fee for the cost of copying and mailing your records. Our copying fees are based upon the State of Illinois Medical Record Copying Fee Guidelines detailed in Public Act 92-228. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program.

We may deny your request to inspect and/or receive a copy in certain limited circumstances. If you are denied access to your PHI, you may request that the denial be reviewed. If we do deny your request, you have the right to have the denial reviewed by a licensed health care professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

Your Right to an Electronic Copy of Electronic Medical Records
If your PHI is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your PHI in the form or format you request, if it is readily producible in such form or format. If the PHI is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Your Right to Get Notice of a Breach
You have the right to be notified upon a breach of any of your unsecured PHI.

Your Right To Amend
If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend that information. You have the right to request an amendment as long as the information to be amended has is kept by or for our office.

To request an amendment, you must submit your request in writing to our Privacy Officer. We may deny your request for an amendment if it is not in writing or does not include specific documentation and reasons to support your request.

In addition, we may deny your request to amend your records if the information in question:

  1. was not created by our practice.
  2. is not part of the health information we normally maintain.
  3. is in records that you are not allowed to inspect or copy.
  4. is already complete and accurate.

Your Right To An Accounting Of Disclosures
You have the right to request a list of disclosures we made of PHI for purposes other than treatment, payment and health care operations. To obtain this list, you must submit a request in writing to our Privacy Officer. We may charge you for the cost of providing this list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any charges have been incurred.

Your Right To Request A Restriction Of Disclosures
You have the right to request a restriction or limitation of the use or disclosure of the PHI we use or disclose for treatment, payment and health care operations as previously described in this document. You also have the right to request a limit on the PHI we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. All such requests for restrictions must be submitted in writing to our Privacy Officer. However, please be advised that we are not required to agree with or grant requests for restrictions unless you are asking us to restrict the use and disclosure of your PHI to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out of pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that you PHI with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

Your Right To Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may request that we only contact you at home, and not at work. To request confidential communications, you must make your request in writing and submit it to our Privacy Officer. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

Your Right To A Paper Copy of This Notice
Even if you have agreed to receive the Notice of Privacy Practices electronically at, you are still entitled to a paper copy of this document at any time. To obtain such a copy, you can go to our website or pick one up in our office during our regular business hours.

We reserve the right to change this notice, and to make the new notice effective for all medical information we already have concerning you, as well as any information we receive in the future. We will post a copy of the current notice at our office and on our web site at, along with its effective date. You are entitled to a paper copy of all such revisions, which may be picked up in our office during our regular business hours as of the effective date.

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. All complaints directed to our office must be in writing, and should be mailed to our Privacy Officer. You will not be penalized for filing a complaint.

This Privacy Notice was created on 9/23/2013, and is effective as of that date.

If you have any questions regarding this notice, you may contact our Privacy Officer, Margo A. Samp, R.N., by writing to her at:

Internal Medicine Associates, S.C.
Attention: Privacy Officer
912 Northwest Highway, Suite 107
Fox River Grove, IL 60021

Internal Medicine Associates

Contact Us

Phone: 847-462-5100
Fax: 847-462-5101

After Hours