Requests for Amendment, Confidential Communication, Restrictions and Accounting of Disclosures Forms

How to Submit Your Forms

  1. Fax: 216-778-8777
  2. Email: [email protected]
  3. The MetroHealth System
    Ethics and Compliance Department
    2500 MetroHealth Dr.
    Cleveland, Ohio 44109

Request a correction to your paper or electronic PHI

  • You can ask us to correct health information about you that you think is incorrect or incomplete.
  • We will respond to your request within 60 days.
  • We may say “no” to your request and will tell you why in writing.
  • Complete the form and return.

Download the Amendment of PHI Request Form (en español)

Request confidential communication

  • 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)

Ask us to restrict the PHI we share

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)

Get a list of those with whom we have shared your PHI

  • 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)