Disclosure & Confidentiality Requests

We may share your PHI electronically with non-MetroHealth providers and health systems through a Health Information Exchange (HIE). This allows your health care providers to access some of your MetroHealth records to coordinate services for you. It also allows us to share your PHI with your insurers for payment purposes.

• If you do not wish to have your PHI shared with a HIE, complete this form.
• We will respond to confirm within 5 business days.

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.
• Complete this form and return.

Download the Confidential Communications Form (en español)

You can ask us not to use or disclose your PHI. We are not required to agree to a restriction request except if:

• The disclosure is for the purpose of carrying out payment or healthcare operations and is not otherwise required by law; and
• The PHI pertains solely to healthcare items or services for which the patient or person (other than the health plan) on behalf of the patient has paid in full.
• Complete the form and return.

Download the Restriction Request Form (en español)

• You can ask for a list (accounting) of when we disclosed your PHI for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as those you asked us to make).
• We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
• Complete the form and return.

Download the Accounting of Disclosures Form (en español)