Patient Privacy Notice

In accordance with Federal Privacy Law (Health Insurance Portability and Accountability Act, HIPAA), Cottonwood Pediatrics keeps medical information and records confidential, and will only use them for patient treatment, health care operations, billing purposes and research.

TREATMENT: Our pediatricians, clinicians, nurses and staff will use your child’s medical information to give him/her the best possible care.

HEALTH CARE OPERATION: Cottonwood Pediatrics will use this information for appropriate follow-up care, patient notification, statistical and regulatory requirements, and internal quality assurance programs.

BILLING PURPOSES: Cottonwood Pediatrics will use your child’s medical information to bill the appropriate third party(ies) for your child’s care. You may choose to not have us bill your insurance carrier, but only if you are paying costs in full on the date of service. The Cash Pay Request Agreement must be completed. If you choose this option, your child’s medical information will not be disclosed to your insurance carrier or health plan.

RESEARCH: Cottonwood Pediatrics may use your child’s medical information for research purposes in coordination with Heartland Research. As a business associate of Cottonwood Pediatrics, Heartland Research has signed a contract which states that they will appropriately safeguard your personal information.

We are legally required to tell you that your child’s personal health information cannot be sold by anyone without your express written authorization, and only after disclosure by the seller of the purpose of sale. However, Cottonwood Pediatrics does not sell any of this information, and never has.

Disclosure of Information with Extenuating Circumstances

  1. Health information will be given to family members in case of an emergency or under other circumstances with proper authorization and documentation.
  2. Health information may be given to other physicians or institutions under emergency situations.
  3. Information may be given to proper authorities when neglect or abuse is alleged or suspected.
  4. Information may be provided to courts or other agencies when a subpoena is served on this office, or by order of the Court.

If you have any questions or concerns about this privacy policy, you may ask to speak to the Cottonwood Pediatrics Privacy Officer, at 316-283-3627. In the event of a breach of security, those parents whose children’s private health information may have been compromised will be notified.

We reserve the right to change the terms of this notice and our privacy policies at any time. Any changes will apply to the medical/financial information we already have. Parents will be notified if any significant changes are made. You may ask for a copy of this privacy notice from any clerical employee at any time.

I hereby acknowledge I was offered a copy of this Notice and either declined or received a copy of such Notice.