If you have any questions about this Privacy Notice, please contact our Privacy Contact at (815) 338-3590.

We respect patient confidentiality and only release medical information about you in accordance with the Illinois and Federal Law. This notice describes our policies related to the use of records of your care generated by this practice.

I. Introduction

In order to effectively provide you care, there are times when we will need to share your protected health information with others beyond our practice. [Protected health information (PHI) means health information (including identifying information about you) we have collected from you or received from your health care providers, health plans, your employer or a health care clearinghouse. It may include information about your past, present or future physical or mental health or condition, the provision of your health care, and payment for your health care services. ] This includes for:

  1. Treatment. We will use and disclose your health information in order to provide your health care and any related services with whom we have received your permission to exchange health information. We will also use and disclose your health information to coordinate and manage your health care and related services.
  2. Payment. Information will be used to obtain payment for the treatment and services provided. This may include contacting your health insurance company or other funding bodies.
  3. For Health Care Operations. We may use information about you to coordinate our business activities. This may include setting up your appointments, reviewing your care, training staff.

II. Information Disclosed Without Your Consent

  1. Emergencies. Sufficient information may be shared to address the immediate emergency you are facing. By way of example, we may provide your health information to a paramedic who is transporting you in an ambulance.
  2. Follow-Up Appointments/Care. We will be contacting you to remind you of future appointments or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
  3. As Required By Law. This would include situations where we have a subpoena, court order, or are mandated to provide public health information, such as communicable diseases or suspected abuse and neglect such as child abuse, elder abuse, or institutional abuse.
  4. Coroners, Funeral Directors, and Organ Donation. We may disclose medical information to a coroner or medical examiner and funeral directors for the purposes of carrying out their duties. When organs are donated sufficient information will be provided to the program as necessary to facilitate the organ or tissue donation.
  5. Governmental Requirements. We may disclose information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure. There might be a need to share information with the Food and Drug Administration related to adverse events or product defects. We are also required to share information, if requested with the Department of Health and Human Services to determine our compliance with federal laws related to health care and to Illinois state agencies that fund our services or for coordination of your care.
  6. Criminal Activity or Danger to Others. If a crime is committed on our premises or against our personnel we may share information with law enforcement to apprehend the criminal. We also have the right to involve law enforcement when we believe an immediate danger may occur to someone.
  7. Fundraising. As a non-for-profit provider of health care services, we need assistance in raising money to carry out our mission. We may contact you to seek a donation. You will have the opportunity to opt out of receiving such communication. You may also opt out of our providing your contact information for any marketing that results in compensation to the Agency.
  8. Military and Veterans. If you are a member of the armed forces, we may disclose your health information as required by military command authorities. We may also disclose your health information for the purpose of determining your eligibility for benefits provided by the Department of Veterans Affairs. Finally, if you are a member of a foreign military service, we may disclose your health information to that foreign military authority.
  9. National Security and Protective Services for the President and Others. We may disclose medical information about you to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law. We may also disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or so they may conduct special investigations.
  10. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose health information about you to the correctional institution or law enforcement official.
  11. Workers’ Compensation. We may disclose health information about you to comply with the state’s Workers’ Compensation Law.

III.   Uses and Disclosures of Your Health Information with Your Permission.

Uses and disclosures not described in Section II of this Notice of Privacy Practices will generally only be made with your written permission, called an “authorization.” You have the right to revoke an authorization at any time. If you revoke your authorization we will not make any further uses or disclosures of your health information under that authorization, unless we have already taken an action relying upon the uses or disclosures you have previously authorized.

IV.  Your Rights

  1. Right to Inspect and Copy. You have the right to request an opportunity to inspect your medical record we have generated. If you request a copy of the information, we may charge a fee for the cost of copying, mailing and supplies associated with your request. Please contact the Privacy Officer for a Request for Health Information form.
  2. Release of Records. You may consent in writing to release of your records to others, for any purpose you choose. This could include your attorney, employer, or others who you wish to have knowledge of your care. You may revoke this consent at any time, but only to the extent no action has been taken in reliance on your prior authorization. Except as described in this Notice or as required by Illinois or Federal law, we cannot release your protected health information without your written consent.
  3. Right to Amend. For as long as we keep records about you, you have the right to request us to amend any health information used to make decisions about your care – whether they are decisions about your treatment or payment of your care. Please contact the Privacy Officer for a Request to Amend Health Information form.
  4. Right to an Accounting of Disclosures. You have the right to request that we provide you with an accounting of disclosures we have made of your health information. An accounting is a list of disclosures. This list will not include certain disclosures of your health information, by way of example, those we have made for purposes of treatment, payment, health care operations or information that you gave us specific consent to release. To request an accounting of disclosures, please contact our
  5. Right to Request Restrictions. You have the right to request a restriction on the health information we use or disclose about you for treatment, payment or health care operations. To request a restriction, you must request the restriction in writing. The Privacy Officer will ask you to sign a Request for Restriction form, which you should complete and return to the Privacy Officer. We are not required to agree to a restriction that you may request. If we do agree, we will honor your request unless the restricted health information is needed to provide you with emergency treatment.
  6. Right to Request Confidential Communications. You have the right to request that we communicate with you about your health care only in a certain location or through a certain method. For example, you may request that we contact you only at work or by e-mail. To request such a confidential communication, you must make your request in writing. We will accommodate all reasonable requests. You do not need to give us a reason for the request, but your request must specify how or where you wish to be contacted.
  7. Notification of Breach. You have a right to be notified if there is a breach of your unsecured protected health information. This would include information that could lead to identity theft. You will be notified if there is a breach or a violation of the HIPAA Privacy Rule and there is an assessment that your protected information may be compromised.
  8. Right to a Paper Copy of this Notice. You have the right to obtain a paper copy of this Notice of Privacy Practices at any time.

V.  Questions and Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. All complaints must be submitted in writing.   We will not retaliate against you for filing a complaint.


VI. Changes to this Notice

Family Alliance, Inc. reserves the right to change the terms of our Notice of Privacy Practices. You may obtain a copy of the current Notice of Privacy Practices by accessing our website at or by calling us at (815) 338-3590 and requesting that a copy be sent to you in the mail or by asking for one any time you are at our offices.



Privacy Officer; Family Alliance; 2028 N. Seminary Ave, Woodstock, IL 60098

Phone Number: (815) 338-3590     Business Hours:   M-F: 9 a.m. – 5 p.m.       Email: