Forms & Consent Policies
Metropolitan Pediatrics has consent policies requiring forms be completed before sharing our child’s medical information with requesting organizations such as schools and daycares. You can download the consent forms listed below.
- Use this form to request records for sporting activities, school, daycare, asthma action plan, allergy action plan, immunization record or medication administration requests sent to any facility.
- We are required by law any time we send protected health information (PHI) to an outside entity that we must have a parent, legal guardian or legal adult child (age 18 or older) consent form signed for each request (one request per form).
- We do not need forms your daycare or school (elementary or high school) provide to you. We do need forms for colleges, Scouts of America, HeadStart and medication administration forms to complete the Form Completion Request.
- When this form is complete, you can drop it off, mail it or FAX it to the clinic that routinely sees your child.
- As are reminder, you child needs to be up-to-date on physical exams to complete any forms. It may take up to 72 hours for completion of your request.
Use this form if you are transferring your child(ren) out of any of our clinics, need specific records shared with a specialist your child(ren) may be seeing, and/or if you are applying for disability benefits or other health care option benefits and law firms. If the child is 18 years old or older, they can sign the form themselves or they must have the 18 Year Old Waiver [18 Year Old Waiver or Consent] that allows parents to sign for their adult children on file with Metropolitan Pediatrics. This release cannot be used for a single form request.
According to Minnesota law and the HIPAA privacy rule, when patients turn 18 years old they are considered adults and parents and guardians can no longer access the patients’ medical information without your child’s written consent. Please have your child fill out this consent form if they would like to provide consent for you (or anyone else) to view their medical record.
Use this consent form to give your permission for another caregiver to temporarily authorize treatment for your child (under 18 years of age) in your absence. This form could be used if you are going out of town, for example, and you are designating care to someone in your absence.
In our practice we use various assessment tools. Below you will find those assessment tools.
Acute Concussion Evaluation (ACE) Physician Office
ADD-ADHD Vanderbilt Assessment Scale-Parent
ADD-ADHD Vanderbilt Assessment Scale-Teacher
ADD-ADHD Vanderbilt Assessment Follow-Up-Parent
ADD-ADHD Vanderbilt Assessment Follow-Up-Teacher
Childhood Asthma Control Test for Children 4 to 11 Years
Childhood Asthma Control Test for Children 12 Years and Older
Edinburgh Postnatal Depression Scale (EPDS)
Generalized Anxiety Disorder Questionnaire (GAD-7)
Modified Checklist for Autism in Toddlers (M-CHAT-R/F)
Patient Health Questionnaire (PHQ-9)
Pediatric Symptom Checklist-Parent
Pediatric Symptom Checklist-Youth
Screen for Child Anxiety Related Disorders-Child
Screen for Child Anxiety Related Disorders-Parent
Other forms are used for administrative purposes such as onboarding a new patient. Those forms are listed below.
Consent for Post-Partum Depression Screening
Patient Demographics and Insurance
Privacy Policy
Effective: January 26, 2026
Contents
1. ABOUT US
2. ABOUT THIS PRIVACY POLICY
3. WHAT PERSONAL INFORMATION WE COLLECT AND HOW WE COLLECT IT?
4. HOW WE USE YOUR PERSONAL INFORMATION?
5. WHAT IS OUR LEGAL BASIS FOR PROCESSING?
6. HOW WE SHARE YOUR PERSONAL INFORMATION?
7. YOUR MARKETING CHOICES
8. RETENTION OF YOUR DATA AND DELETION
9. INTERNATIONAL TRANSFERS
10. YOUR DATA PROTECTION RIGHTS
11. CHANGES TO THIS PRIVACY POLICY
12. CONTACT US
1. ABOUT US
“We”, “us” or “our” means Metropolitan Pediatrics, with its principal place of business located at 3400 W 66th St Ste 450 Edina MN US 55435-2115.
2. ABOUT THIS PRIVACY POLICY
Your privacy is important to us, so we’ve developed this Privacy Policy, which explains how we collect, use, and disclose your personal information. We collect personal information when you use our website(s), mobile apps, and other online and offline products, services and experiences (collectively, the “Services”). Please take a moment to read through this Policy in its entirety.
If you have any questions, concerns or complaints regarding this Privacy Policy or how we use your personal information please contact us via e-mail at morgananderson@metropeds.com.
3. WHAT PERSONAL INFORMATION WE COLLECT AND HOW WE COLLECT IT?
We collect personal information that you provide directly to us:
Contact information. If you sign up to receive our newsletter, emails, or text messages from us, we will collect your name, email address, mailing address, phone number, and any other information needed to contact you about the Services.
Payment information. To order products or services through the Services, you will need to provide us with payment information (like your bank account or credit card information). Please note that your financial information is collected and stored by a third party payment processing company. Use and storage of that information is governed by the third party payment processor’s applicable privacy policy.
Survey information. You may provide us with other personal information when you fill in a form, respond to our surveys or questionnaires, provide us with feedback, participate in promotions, or use other features of the Services.
Communications information. We may also collect other information during our communications with you, including information that you send to us when interacting with our customer service agents, or when you call us or send emails or text messages. This may include information about how you contacted us, your marketing preferences, and other information that you choose to share.
4. HOW WE USE YOUR PERSONAL INFORMATION?
We use the personal information we collect for the following reasons:
- To send you our newsletter, or other information or marketing about our Services that you think may be of interest to you.
- To reply to your questions, inquiries, or customer service requests or to send you notices, updates, security alerts, or support and administrative messages.
- To provide you with information about the Services that you request from us or which we feel may interest you.
- To monitor and analyze trends, usage and activities in connection with our Services and to improve the Services.
- To facilitate contests, sweepstakes and promotions, and to process entries and provide prizes and rewards.
- To detect, investigate and prevent fraudulent transactions and other illegal activities on the Services and to protect the rights and property of us and our customers.
- To carry out our obligations arising from any contracts entered into between you and us, including for billing and collection.
We may also use your personal information to fulfill our obligations as set out by the applicable law, or to carry out any other purpose as described to you at the time your personal information was collected.
5. WHAT IS OUR LEGAL BASIS FOR PROCESSING?
In certain countries we are required to have a legal basis for collecting and using your personal information.Our legal basis will depend on the personal information concerned and the specific context in which we collect it. We will normally collect personal information from you only where we have your consent to do so, where we need your information to perform a contract with you, or where the processing is in our legitimate interests and not overridden by your fundamental rights. In some cases, we may also have a legal obligation to collect personal information from you or may otherwise need the personal information to protect your vital interests or those of another person.
If you have questions about or need further information concerning the legal basis on which we collect and use your personal information, please contact us using the details provided in the “Contact Us” section below.
6. HOW WE SHARE YOUR PERSONAL INFORMATION?
We may share your personal information in the following ways:
- With vendors, consultants, and other service providers who process your personal information on our behalf when they provide services to us, for example data analytics, research, marketing and financial services.
- In connection with, or during negotiations of, any merger, sale of company assets, financing or acquisition of all or a portion of our business by another company.
We may be legally required to disclose or share your personal information without your consent in some circumstances, for example to comply with a court order or law enforcement. In such circumstances, we will only disclose your personal information if we have a good-faith belief that such sharing is required under applicable legal obligations.
7. YOUR MARKETING CHOICES
When you sign up for a promotion like a sweepstakes, or subscribe to receive our newsletter or marketing/promotional messages, we use your personal information to help us decide which products, services and offers may be of interest to you.
We will send marketing messages to you if you have asked us to send you information, bought goods or services from us, or if you provided us with your details when you entered a competition or registered for a promotion. If you opt out of receiving marketing messages, we may still send you non-promotional emails. We will ask for your consent before we share your personal information with any third party for their direct marketing purposes.
You may unsubscribe from marketing messages through a link we include on messages we send you. You can also ask us to stop sending you marketing messages at any time by contacting us at: morgananderson@metropeds.com.
8. RETENTION OF YOUR DATA AND DELETION
Your personal information will not be kept longer than is necessary for the specific purpose for which it was collected.
When we decide how long we will keep your information we consider the amount, nature, and sensitivity of the personal information, the potential risk of harm from unauthorized use or disclosure, why we need it, and any relevant legal requirements (such as legal retention and destruction periods).
The foregoing will, however, not prevent us from retaining any personal information if it is necessary to comply with our legal obligations, in order to file a legal claim or defend ourselves against a legal claim, or for evidential purposes.
Details of retention periods for different aspects of your personal data are available from us on request by contacting us using the contact details provided under the “Contact Us” heading below.
9. INTERNATIONAL TRANSFERS
We will ensure that any transfer of personal information to countries outside of the United States will take place pursuant to the appropriate safeguards.
10. YOUR DATA PROTECTION RIGHTS
Depending on the circumstances, you may have some of the following rights under applicable data protection laws. To exercise any of them, please contact us using the details provided in the “Contact Us” section below
- You may access, correct, or request deletion of your personal information
- You may object to processing of your personal information, ask us to restrict processing of your personal information or request portability of your personal information, (i.e. your data to be transferred in a readable and standardized format).
- If we have collected and processed your personal information with your consent, then you can withdraw your consent at any time.
We respond to all requests we receive from individuals wishing to exercise their data protection rights in accordance with applicable data protection laws.
You may also have the right to complain to a supervisory authority about our collection and use of your personal data. For more information, please contact your local supervisory authority.
11. CHANGES TO THIS PRIVACY POLICY
From time to time, we have the right to modify this Privacy Policy. We’re likely to update this Privacy Policy in the future and when we make changes. When we update this Privacy Policy, we will take appropriate measures to inform you, consistent with the significance of the changes we make.Please come back and check this page from time to time for the latest information on our privacy practices.
12. CONTACT US
The data controller of your personal information is Metropolitan Pediatrics, with its principal place of business located at 3400 W 66th St Ste 450 Edina MN US 55435-2115.
If you have questions or concerns about the information in this Privacy Policy, our handling of your personal information, or your choices and rights regarding such use, please do not hesitate to contact us at:
Metropolitan Pediatrics
3400 W 66th St Ste 450 Edina MN US 55435-2115
management@metropeds.com