This notice describes how information about you may be used and disclosed and how you can get access to this information.

During treatment at VitreoRetinal Surgery, doctors, technicians and other caregivers may gather information about your medical history and health. This notice will explain how such information may be used and shared with others. It will also explain privacy rights regarding this kind of information.

When we refer to “you” or “your” in the Notice, we refer to the patient. When we refer to types of disclosures of information to “you”, we mean disclosure to the patient, the patient’s guardian, or person legally authorized to receive information about the patient.

Medical information may be used for the following purposes:

  • Treatment: We will use your information to provide, coordinate, and manage care and treatment. For example, a physician may share medical information with another physician for consultation or a referral.
  • Payment: We will use information to receive payment for the services we provide. For example, we will disclose information in order to submit bills or claims to insurance companies and Medicare or Medicaid.
  • Health Care operations: We will use information for certain activities related to the functioning of VitreoRetinal Surgery. For example, we may use or disclose information for quality assurance activities.
  • Appointment reminders and other health information: We may use information to call you or send you reminders about future appointments. We may also contact you with information about new or alternative treatments or other health care services.
  • Fundraising: We may use information to notify you about fund-raising campaigns or other charitable events.
  • Family members or other responsible people: We may disclose information to people who will be taking care of you or are responsible for paying bills, such as other family members. VitreoRetinal Surgery will only disclose medical information that these people need to know. We may also use information to let other family members or other responsible people know where you are and what your general medical condition is. If you are able to make your own health care decisions, VitreoRetinal Surgery will ask permission before using medical information for these purposes. If you are unable to make health care decisions, VitreoRetinal Surgery will disclose relevant medical information to family members or other responsible people if we feel it is in the patient’s best interests to do so. For example, we may provide limited medical information to allow another family member to pick up a prescription or x-ray for you.
  • Emergency conditions: Under emergency conditions, we may disclose information about you to the government or other groups that assist in emergencies or disasters.
  • Other uses or disclosures: VitreoRetinal Surgery may disclose or use information in the following cases: when required by law; for public health activities; relating to victims of abuse, neglect, or domestic violence; for health oversight activities; for judicial and administrative proceedings to the extent permitted by law; for law enforcement purposes, as permitted or required by law; to coroners, medical examiners, and funeral directors, as permitted by law; for organ donation purposes; for research purposes under certain circumstances; to avert a serious threat to health or safety; for certain specialized government functions, such as military discharge and national security and intelligence; and for worker’s compensation purposes.
  • Research: Federal law permits VitreoRetinal Surgery, PLLC to use and disclose medical information about you for research purposes, either with your specific written authorization or when the study has been reviewed for privacy protection by an Institutional Review Board or Privacy Board before the research begins. In some cases, researchers may be permitted to use information in a limited way to determine whether the study or the potential participants are appropriate. Minnesota law generally requires that we get your general consent before we disclose your health information to an outside researcher. We will make a good faith effort to obtain your consent or refusal to participate in any study, as required by law, prior to releasing any identifiable information about you to outside researchers.


  • Restrict use and disclosure: You may request that VitreoRetinal Surgery not use medical information in certain ways or for certain purposes. You may also request that VitreoRetinal Surgery not provide medical information to certain people. However, VitreoRetinal Surgery has the right to refuse your request. VitreoRetinal Surgery may use or disclose your medical information in situations requiring emergency treatment, in which case we will ask the person(s) who receives the information not to further use or disclose the information.
  • Provide confidentiality: You may request that VitreoRetinal Surgery provide you with your medical information in a confidential manner. For example, you can request that we send appointment reminders, bills, and other mailings to a different address or that we notify you of this kind of information in another way, such as by telephone call. You must make this request in writing and specify another address or means of communication. We must agree to your written request. We may also ask you to give us information about how you will pay your bills.
  • Inspection and copy: You may ask to see and copy your medical records, unless that information is protected by law. You must make these requests in writing. If your request to look at or copy your medical records is denied, you have the right to have the denial reviewed by a health care professional. We will act upon your request within 30 days and may charge you a legally acceptable amount for copying costs.
  • Change information or amend medical records: You may ask us to change information in your medical records. If your request is denied, you can write a statement of disagreement with the denial that we will keep with your medical information.
  • Accounting of disclosures: You may ask us to provide you with information about certain disclosures of your medical information we made in the past. Requests for accountings will not be made prior to April 14, 2003. Your request can go back six years but will not include disclosures made prior to April 14, 2003.
  • Paper copy:  If you have received this notice of the medical information privacy rights electronically, you may ask us to provide you with a paper copy.
  • Privacy violations: If you feel your medical information privacy rights have been violated, you may file a complaint with the Secretary of Health and Human Services and/or with VitreoRetinal Surgery and you will not be retaliated against for filing a complaint.

The U.S. Dept. of Health and Human Services
200 Independence Ave. S.W.
Washington, D.C. 20201
(202) 619-0257
Toll free: 1-877-696-6775

VitreoRetinal Surgery privacy official: You may contact the designated privacy official at VitreoRetinal Surgery.

Privacy Officer: Mary Nordenstrom
Address: 7760 France Ave. S. #310
Minneapolis, MN 55435
Phone: 952-259-3448

The effective date of this notice is April 14, 2003. VitreoRetinal Surgery is required by law to maintain the privacy of protected health information and to provide individuals with this notice of its legal duties and privacy practices with respect to health information. VitreoRetinal Surgery is required to abide by the terms of the notice currently in effect. VitreoRetinal Surgery reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information maintained by VitreoRetinal Surgery. If the terms of this notice are changed, VitreoRetinal Surgery will provide individuals with a revised notice at the time of treatment, or upon request, by posting the revised notice in designated locations at VitreoRetinal Surgery.