ILLINOIS NOTICE FORM

Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your 

Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION 

ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS 

INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations 

I may use or disclose your protected health information (PHI), for treatment, payment, and 

health care operations purposes with your written authorization. To help clarify these terms, 

here are some definitions: 

 “PHI” refers to information in your health record that could identify you. 

 “Treatment, Payment, and Health Care Operations”

– Treatment is when I provide, coordinate, or manage your health care and other services 

related to your health care. An example of treatment would be when I consult with 

another health care provider, such as your family physician or another psychologist.

– Payment is when I obtain reimbursement for your healthcare. Examples of payment are 

when I disclose your PHI to your health insurer to obtain reimbursement for your health 

care or to determine eligibility or coverage.

– Health Care Operations are activities that relate to the performance and operation of 

my practice. Examples of health care operations are quality assessment and improvement 

activities, business-related matters such as audits and administrative services, and case 

management and care coordination.

 “Use” applies only to activities within my [office, clinic, practice group, etc.] such as 

sharing, employing, applying, utilizing, examining, and analyzing information that identifies 

you.

 “Disclosure” applies to activities outside of my [office, clinic, practice group, etc.], such as 

releasing, transferring, or providing access to information about you to other parties. 

 “Authorization” is your written permission to disclose confidential mental health 

information. All authorizations to disclose must be on a specific legally required form.

II. Other Uses and Disclosures Requiring Authorization 

I may use or disclose PHI for purposes outside of treatment, payment, or health care operations 

when your appropriate authorization is obtained. In those instances when I am asked for 

information for purposes outside of treatment, payment, or health care operations, I will obtain 

an authorization from you before releasing this information. I will also need to obtain an 2

authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes I 

have made about our conversation during a private, group, joint, or family counseling session, 

which I have kept separate from the rest of your record. These notes are given a greater degree 

of protection than PHI. 

You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided 

each revocation is in writing. You may not revoke an authorization to the extent that (1) I have 

relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining 

insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures without Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances: 

 Child Abuse – If I have reasonable cause to believe a child known to me in my professional 

capacity may be an abused child or a neglected child, I must report this belief to the 

appropriate authorities.

 Adult and Domestic Abuse – If I have reason to believe that an individual (who is protected 

by state law) has been abused, neglected, or financially exploited, I must report this belief to 

the appropriate authorities.

 Health Oversight Activities – I may disclose protected health information regarding you to a 

health oversight agency for oversight activities authorized by law, including licensure or 

disciplinary actions.

 Judicial and Administrative Proceedings – If you are involved in a court proceeding and a 

request is made for information by any party about your evaluation, diagnosis and treatment 

and the records thereof, such information is privileged under state law, and I must not release 

such information without a court order. I can release the information directly to you on your 

request. Information about all other psychological services is also privileged and cannot be 

released without your authorization or a court order. The privilege does not apply when you 

are being evaluated for a third party or where the evaluation is court ordered. You must be 

informed in advance if this is the case.

 Serious Threat to Health or Safety – If you communicate to me a specific threat of imminent 

harm against another individual or if I believe that there is clear, imminent risk of physical or 

mental injury being inflicted against another individual, I may make disclosures that I believe 

are necessary to protect that individual from harm. If I believe that you present an imminent, 

serious risk of physical or mental injury or death to yourself, I may make disclosures I

consider necessary to protect you from harm.

 Worker’s Compensation – I may disclose protected health information regarding you as 

authorized by and to the extent necessary to comply with laws relating to worker’s 

compensation or other similar programs, established by law, that provide benefits for workrelated injuries or illness without regard to fault.3

IV. Patient’s Rights and Psychologist’s Duties

Patient’s Rights:

 Right to Request Restrictions – You have the right to request restrictions on certain uses and 

disclosures of protected health information. However, I am not required to agree to a 

restriction you request. 

 Right to Receive Confidential Communications by Alternative Means and at Alternative 

Locations – You have the right to request and receive confidential communications of PHI by 

alternative means and at alternative locations. (For example, you may not want a family 

member to know that you are seeing me. On your request, I will send your bills to another 

address.) 

 Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in 

my mental health and billing records used to make decisions about you for as long as the PHI 

is maintained in the record and Psychotherapy Notes. On your request, I will discuss with 

you the details of the request for access process. 

 Right to Amend – You have the right to request an amendment of PHI for as long as the PHI 

is maintained in the record. I may deny your request. On your request, I will discuss with 

you the details of the amendment process. 

 Right to an Accounting – You generally have the right to receive an accounting of disclosures 

of PHI. On your request, I will discuss with you the details of the accounting process. 

 Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me 

upon request, even if you have agreed to receive the notice electronically.

Psychologist’s Duties:

 I am required by law to maintain the privacy of PHI and to provide you with a notice of my 

legal duties and privacy practices with respect to PHI.

 I reserve the right to change the privacy policies and practices described in this notice. 

Unless I notify you of such changes, however, I am required to abide by the terms currently 

in effect. 

 If I revise my policies and procedures, I will . . .[Notice must also describe how the 

psychologist will provide individuals with a revised notice, e.g., by mail.]

V. Questions and Complaints

If you have questions about this notice, disagree with a decision I make about access to your 

records, or have other concerns about your privacy rights, you may contact James Wellman, 

Psy.D. at (773) 398-3332.4

If you believe that your privacy rights have been violated and wish to file a complaint with 

me/my office, you may send your written complaint to James Wellman, Psy.D. at 3660 North 

Lake Shore Drive, Suite 210 Chicago, IL 60613.

You may also send a written complaint to the Secretary of the U.S. Department of Health and 

Human Services. The person listed above can provide you with the appropriate address upon 

request.

You have specific rights under the Privacy

Rule. I will not retaliate against you for exercising 

your right to file a complaint.