In all other ways, we will require your written permission before your health information is used or shared with others.

Except as stated above, your written permission is required before we can use or share your health information with anyone outside of our office. This permission is provided through an authorization to release medical information form. If you give us permission to use or share health information about you, you may cancel that permission, in writing, at any time. If you cancel your permission, we will no longer use your health information for the reasons you have given us in your revocation of permission. However, we are unable to take back any information that we have already shared with your permission.

Your Rights Concerning Your Health Information

The law gives you the following rights about your health information:

RIGHT TO ASK TO SEE AND COPY.

You have the right to ask to see and copy the health information we used to make decisions about your care. This request must be in writing and given to our Privacy Officer. If you ask to see or copy your health information, you will have to pay for costs of copying, mailing or other costs and this will be done by appointment. We may tell you that you cannot see or copy some or all of your health information If we tell you this, you may ask that someone else in our office review this decision.

RIGHT TO ASK FOR AN AMENDMENT (CORRECTION).

If you feel that health information we have about you is incorrect or incomplete, you may ask us to correct the information. You have the right to ask for an amendment for as long as the information is kept by or for Family Medical Care Plus Inc. You must put your request in writing and give it to our Privacy Officer.

WE HAVE THE RIGHT TO REFUSE YOUR REQUEST.

If you ask us to amend information that was not made by us, is not part of the health information kept by our office, is not part of the information you are permitted by law to see and copy, or that we believe is correct and complete.

RIGHT TO ASK FOR AN ACCOUNTING OF DISCLOSURES.

You have the right to ask us for an accounting of non-routine disclosures. This is a list of those people outside of Family Medical Care Plus Inc. that have received your health information except for information shared for treatment, payment, healthcare operation or when you have provided us with permission to do so. You must put your request in writing and give it to our Privacy Officer. You must include in your written request how far back in time you want us to go. It may not be longer than six years and may not include dates before April, 2003, which is the date when by law we are required to begin keeping track of the disclosures. There will be a charge if the same information is requested more than once within twelve months.

RIGHT TO ASK FOR LIMITS ON USE AND SHARING.

You have the right to ask us to limit the health information we share with others about you for treatment, payment, healthcare operations or that we share with someone who is involved in your care of payment for your care, like family or friend. You can call our office and get instructions on how to submit such a request. In your request you must tell us: what information you want to limit, whether you want to limit our use, disclosure of both and the person or institution the limits apply to (for example your spouse). WE ARE NOT REQUIRED TO AGREE TO YOUR REQUEST. If we do agree to your request, the only time we will not follow your request is if the information you want us to limit is needed to tie you emergency treatment.

RIGHT TO ASK FOR A PAPER COPY OF THIS NOTICE.

You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. To receive a paper copy of this notice please contact our Privacy Officer at 330.633.3883.

Violation of Privacy Rights

If you believe your privacy rights have been violated you may file a complaint in writing by mailing a completed Privacy Complaint Form to: FAMILY MEDICAL CARE PLUS, INC. attention Privacy Officer at our current address. These forms are available in our office. Individuals wishing to file a complaint may also do so by calling the Corporate Compliance Helpline/Hotlain at 1.877.820.3037. You may also file a complaint with the Secretary of the US Department of Health and Human Services in Washington, DC in writing within 180 days of a violation of your rights. YOU WILL NOT BE PENALIZED FOR FILING A COMPLAINT.

Changes to This Notice

We reserve (have) the right to change this notice. We have the right to make the revised or changed notice effective for health information we already have about you and for health information we receive in the future. We will post a copy of the current notice in our patient waiting area. The notice will contain the effective date on the front page of this letter. We will provide you, if you ask us, with a copy of the notice is currently in effect each time you visit our office for treatment of healthcare services.