Foster Information - Cottonwood Pediatrics

Placement Information

In addition to the new patient form, please fill out foster information below – HIPAA protected. You can also use the printable PDF.

Child Information

Child's Full Name *

Date of Birth *

Foster Parent Information

Full Name *

Date of Birth *

Foster Parent Information

Full Name

Date of Birth *

Placement Information

Case Manager Name *

Organization *

Date of Placement

Office Phone Number

Extension Number

Cell Phone Number

Fax Number

Case Number

Today's Date

Medical Consent

I have the placement/guardianship papers for this child.

Due to HIPAA regulations, we require this paperwork BEFORE seeing a foster patient.

Health Records

To provide appropriate medical care and meet KDHE requirements, please present or sign the release for the patient's past medical history, including but not limited to:

Current health or development concerns,Current medicationsAny unknown drug allergiesImmunizationsDate of patient's last physical/well child check

Please note: if a foster child has commercial insurance, we may not be able to see her/him, especially under HMO plans. If locked in to another provider, it may be advisable to seek care with the PCP listed with the HMO.