Orrville Office-830 S. Main St Suite 102 Orrville, Ohio 44667 PH: 330-765-9104 Fax: 330-682-0747

Massillon Office- 100 Lillian Gish Blvd SW, Suite 201 Massillon, Ohio 44647 PH: 330-809-0460 Fax: 330-809-0560

Notice of Privacy Practices This Notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully.   Who Will Follow This Notice The privacy Practices described in this notice will be followed by members of this healthcare team, which includes all the healthcare professionals, employees, medical staff, trainees, students, volunteers, and business associates of Nicholas Sherock, D.O., Sarah Barber, D.O. or Richele Thompson CNP, CNM.   Our Pledge to You We understand that health information about you is personal. My OB/GYN is committed to protecting your health information. This Notice applies to all of the health records that identify you and the care that you receive under our providers here at my OB/GYN. We are legally required to maintain the privacy of our patients’ health information, provide you with a copy of this Notice, and to follow the terms of the notice that is currently in effect.   How We Use and Disclose Health Information about You The members of my OB/GYN healthcare team may share your health information with each other for reasons of treatment, payment, and healthcare operations. Sharing this information makes it possible for our providers and their team to care for you thoroughly and efficiently. Everyone is required to protect your health information.   Your Authorization Expect as outlined in the following pages, we will not use or disclose your health information for any reason unless you have signed a form authorizing us to do so. You have the right to cancel your authorization in writing unless we have taken any action in reliance on the authorization.   NOTICE OF PRIVACY PRACTICES   Uses and Disclosures for Treatment We will use and disclose your health information as needed for your treatment. For example, doctors and nurses, and other professionals involved in your care will use information in your medical record, and/or information that you give them, in order to treat you. We may also disclose your health information to another care facility or professional that is not affiliated with my OB/GYN, but who is or may be providing treatment to you. For instance, if you are going to receive treatment at a hospital after you leave the office, we may release your health information to that hospital so that they can treat you.   Uses and Disclosures for Payment We will use and disclose your health information for the purpose of allowing us, as well as other entities, to secure payment for your health care services provided to you. For example, we may forward information regarding your medical treatment to your health plan to arrange payment for the services we provided to you. We may also tell your health plan about your treatment you are going to receive in order to obtain prior approval or to determine whether your health plan will cover treatment.   Uses and Disclosure for Health Care Operations We will use and disclose your health information as needed, and as permitted by laws, in the process of our daily operations. These operations may include, but not limited to: clinical improvement, professional peer review, business management, accreditation and licensing. For example, we may use and disclose your health information for purposes of improving the clinical treatment and care of our patients or to determine the needs and preference of our patients. We may also disclose your health information to another facility, healthcare professional, or other covered entity, for such things as quality assurance and case management, but only if they have, or had, a patient relationship with you. We will provide any subsequent physician or healthcare provider with copies of your healthcare information that should assist him or her in continuing course of treatment.   Family and Friends Involved In Your Care With your approval, we may disclose your health information to designated family, friends and others who are involved in your care, or in payment of your care. If you are unable to give approval, or facing an emergency situation, we may then share parts of your health information with such individuals without your approval in order to treat you. We may also disclose limited health information to an entity that is authorized to assist in disaster relief efforts, so your family can be notified of your condition, status, and location.   Business Associates We may contact you with reminders or test results. You may request that we provide this information by another means or at another location. For example, if you do not want appointment reminders left on voice mail or sent to a certain address, we will make every effort to accommodate reasonable requests. Please make this request in writing to medical records at my OB/GYN where you received services.   Health Insurance Exchanges We may participate in health information exchanges that facilitate the secure exchange of your electronic health information between, and among, several healthcare entities for your treatment, payments, and or other healthcare operations purposes. This means we may share information we obtain or create about you with outside entities (such as hospital, doctors’ offices, pharmacies, or health plans), or we may receive information they create or obtain about you (such as medication history, medical history, treatment notes, or insurance information) so each of us can provide better, safer treatment, and coordination of your health care services.   Research In limited cases, we may use or disclose your health information for research purposes. For example, a research organization may wish to compare all patients who received a certain drug and will thus need to review records. In all cases where your specific authorization has not been obtained, your privacy will be protected by strict confidentiality requirements. These requirements are applied by an Institutional Review Board that oversees the research or by representations of the researcher that will limit their use and disclosure of patient information.   Marketing We must receive your authorization for any use or disclosure of your health information for marketing, unless the communication is made directly to you in person, is simply a promotional gift of nominal value, is a prescription refill reminder, is general health or wellness information, or a communication, about health-related products or services that we offer or that are directly related to your treatment.   NOTICE OF PRIVACY PRACTICES   Sales of Health Information We must receive your authorization for any sale of your health information unless for treatment or payment purposes or as required by law.   Fundraising Activities We may contact you to donate to a fundraising effort for or on our behalf. You have the right to “opt-out” of receiving fundraising materials or communication by submitting your name and address to my OB/GYN, 830 S. Main St STE 102, Orrville Ohio 44667 in writing with a statement that you do not wish to receive fundraising materials or communications from us.   Incidental Disclosures Although we take reasonable measures to ensure your privacy, certain disclosures of your health information may occur incidentally. For example, other patients may see your name on a sign in sheet, or you may overhear a physician’s confidential conversation with another provider or patient.   Teaching My OB/GYN may at times provide education opportunities to residents, students in medicine, nursing staff, medical staff, radiology, pharmacy, allied health and other studies. These individuals may be assisting with your care under the supervision of a licensed health care provider as part of their professional health care training program.   Organ and Tissue Donation As necessary, we may use or disclose your health information to an organization that arranges organ donation, eye or tissue procurements, transplants or donation to an organ donation bank.   NOTICE OF PRIVACY PRACTICES Other Uses or Disclosures of Information We are permitted or required by law to make certain other uses and disclosures of your health information without your consent or authorization as follows:

• For any purpose required by law
• For public health activities, such as required reporting disease, injury, birth and death; and for public health investigations.
• If we suspect child abuse or neglect; or if we think you are a victim of abuse, neglect or domestic violence.
• To release immunization records to a student’s school, but only if a parent or guardian (or the student, if not a minor) agrees either orally or in writing.
• To the Food and Drug Administration, if necessary, to report adverse events or product defects or to participate in product recalls.
• To your employer when we have provided health care to you at the request of your employer to determine workplace-related illness or injury; in most cases you will receive notice that information is disclosed to your employer
• To government agencies conducting audits, investigations or civil or criminal proceedings. If required to do so by subpoena or discovery request; in some cases you will have notice of such release.

  Other Uses and Disclosures of information  

• To law enforcement officials as required by law or to report wounds or injuries and crimes
• To coroners and funeral directors consistent with the law
• If you are an inmate of a correctional institution or under the custody of the law enforcements officials, we may release information about you to the correctional institution as authorized or required by law.
• In limited instances, if we suspect a serious threat to health or safety
• If you are a member of the military, as required by armed forces, we may also release information, if necessary, for your worker’s compensation befit determination.
• As required by Ohio law. Ohio law requires that we obtain consent from you in many instances before disclosing the performance results of an HIV test or diagnosis of AIDS or an AIDS-related condition; before disclosing information about drug or alcohol treatment you have received in a drug or alcohol treatment program; before disclosing information to the State Long Term Care Ombudsman. For more information on when such consents may be necessary, you can contact the Compliance Department listed at the end of this notice.

  Notice of Privacy Practices   You’re Rights Regarding Health Information about You Right to Inspect and Copy You have the right to request a copy and/or inspect much of the health information that we keep on your behalf. All requests to inspect or copy must be made in writing and signed by you or your representative. If your request copies, you will be charged our regular fees for copying and mailing the requested information. You may obtain an authorization request form and a fee schedule from the medical records department at the office of my OB/GYN.   Right to Electronic Copies You have the right to obtain an electronic copy of your health information that we keep on your behalf and that exists in an electronic format. You may direct that the copy be transmitted directly to an entity or person designated to you, provided that any such designation is clear, conspicuous, and specific with complete name and mailing address or other identifying information. We will charge you a fee for our labor and supplies in preparing your copy of the electronic health information.   Right to Amend You have the right to request in writing that the health information we maintain about you be amended and corrected. We are not required to make all the changes or corrections you request. However, we will give each request careful consideration. All requests must be in writing, be signed by you or your representative, and must state the reasons for the amendment or correction. If an amendment or correction you request is made by us, we may also notify others who work with us and have copies of the uncorrected record if we believe that such notification is necessary. You may obtain an amendment request form from the medical records department at my OB/GYN where your services were received.   Right to an Accounting of Disclosures You have the right to an accounting of certain disclosures we have made of your health information. Requests must be made in writing and signed by you or your representative. The first accounting in any 12 month period is free; you will be charged our regular fees for each subsequent accounting you request with the same 12 month period. You may obtain an accounting request form and fee schedule from the medical records department of my OB/GYN where you received services.   Notice of Privacy Practices   Right to Request Individual Restrictions You have the right to request restrictions on certain uses and disclosures of your health information for treatment, payment or health care operations. In most cases, we are not required to agree to your restriction request but will attempt to accommodate reasonable request as appropriate, and we may terminate an agreed-to restriction if we believe such termination is appropriate. We will tell you if we agree with your request or not. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. We will notify you if we terminate a requested restriction. We will honor any request to restrict disclosures to your health care plan the information to be disclosed pertains solely to a health care item or service for which my OB/GYN has been paid in full, You may obtain a restriction request form from the medical records department of the office of my OB/GYN where you received services.   Breach notification In the unlikely event that there is a breach, or unauthorized release of your personal health information, you will receive notice and information on steps you may take to protect yourself from harm.   Changes to This Notice We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make the new notice effective for all health information maintained by us. You may obtain a copy of the current notice from the office where you received services. Or by mailing a request to my OB/GYN compliance department listed below.   Complaints If you believe your privacy rights have been violated, you may file a complaint in writing to my OB/GYN, 830 S. Main St Suite 102 Orrville, OH 44667. You may also file a complaint in writing with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C. There will be no retribution for filing a complaint.   Acknowledgement of Receipt of Notice You will be asked to sign a form that you received this Notice of Privacy Practices. You have the right to obtain a paper copy of this notice upon request, even if you have requested such a copy by email or other electronic means. Paper copies may be obtained from your physician’s office.