Metro Urology

You have the following rights regarding health information about you.

1. Right to Request Restrictions – You have the right to request a restriction or limitation on the health treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose about you/your child to someone who is involved in your/your child’s treatment or for the payment for that care. In most cases, we are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to our Privacy Officer, Metro Urology, 2550 University Ave. W, Suite 240 North, St. Paul, MN 55114. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you wants the limits to apply.

2. Right to Inspect and Copy – You have the right to inspect and copy health information that may be used to make decisions about you/your child’s care. To inspect and copy health information that may be used to make decisions about you/your child, you can submit your request in writing to our Release of Information Clerk, Metro Urology, 2550 University Ave. W, Suite 240 North, St. Paul, MN 55114. If you request a copy of information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We will have 30 days to respond to your request for information that we maintain on site. If the information is stored off-site, we are allowed up to 60 days to respond but must inform you of this delay.

3. Right to Amend – You have the right to ask us to amend your/your child’s health and/or billing information for as long as the information is kept by Metro Urology. To request an amendment, your request must be made in writing and submitted to; Privacy Officer, Metro Urology, 2550 University Ave. W, Suite 240 North, St. Paul, MN 55114. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request.

We may deny your request if you ask us to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
• Is not part of the health information kept by Metro Urology.
• Is not part of the information, which you would be, permitted to inspect or copy.
• Is accurate and complete.

4. Right to an Accounting of Disclosures – You have the right to request a list of certain disclosures that we have made of your/your child’s health information. To request this list of disclosures, you must submit your request in writing to; Privacy Officer, Metro Urology, 2550 University Ave. W, Suite 240 North, St. Paul, MN 55114. Your request must state a time period that may not be longer than six years and may not include dates before April 14, 2003. Your request should indicate in which form you want the list (for example; on paper, electronically). The first list you request within a 12-month period will be free. For additional lists during such 12-month period, Metro Urology may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

5. Request Confidential Communication – You have the right to request how we communicate with you to preserve your privacy. Your request must be in writing and must specify how or where we are to contact you. We will accommodate all reasonable requests.

6. Complaints – If you believe your/child’s privacy rights have been violated, you may file a complaint with Metro Urology or with the Secretary of Health and Human Services. To file a complaint with Metro Urology, provide as much detail as you can about the suspected violation and send it to; Privacy Officer, Metro Urology, 2550 University Ave. W, 240 North, St. Paul, MN 55114. You should know that there would be no retaliation for your filing a complaint.

If you have any questions about this Notice, please contact:

2550 University Avenue West
Suite 240 North
St. Paul, MN 55114
651-999-7009