Children's physician group joint notice of privacy practices



This information is available in Spanish. Please ask a staff member if you need a copy. Esta información esta disponible en español. Si necesita una copia en español, pídala a un miembro del personal. Véase el Aviso conjunto de prácticas de privacidad en español.

Most patients of Children's Physician Group, Inc., are children; when we refer to "you" or "your" in this notice, we refer to the patient. When we refer to disclosures of information to "you," we mean disclosures to the patient, the patient's parent, guardian or other person legally authorized to receive information about the patient.

This notice applies to all patient health information maintained by Children's Physician Group, Inc. for services provided.

If you have any questions after reading this notice, please contact Children's Physician Group's privacy officer.

Each time you visit Children's Physician Group, your physician or other health care provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment and billing-related information. This notice applies to all of the records of your care generated by Children's Physician Group, whether made by Children's Physician Group employees, agents or your physician.

We are required by law to maintain the privacy of your health information and provide you with this description of our privacy practices. We will abide by the terms of this notice.


  • Treatment
    We will use health information about you to provide you with medical treatment or services. We will disclose health information about you to doctors, residents, nurses, technicians, students in health care training programs, or to Children's Physician Group personnel who are involved in taking care of you. For example, a physician treating you for a broken leg may need to know if you have diabetes because diabetes might slow the healing process.
  • Payment
    Children's Physician Group will use and disclose your health information to send bills and collect payment from you, your insurance company, or other payors, such as Medicaid, for the care, treatment and other related services you receive from Children's Physician Group. We also may tell your health insurer about a treatment your physician has recommended in order to obtain prior approval or to determine whether your plan will cover the treatment.
  • Healthcare Operations
    We may use and disclose health information about you for Children's Physician Group business operations. These uses and disclosures are necessary to run Children's Physician Group and make sure that all of our patients receive quality care and cost-effective services. For example, we may use health information to review the quality of our treatment and services, to develop new programs as part of promoting health and to evaluate our performance in caring for you.

We also may combine our health information with health information from other Children's Physician Group sites for our staff and students to improve our care and services. In these instances, we remove information that identifies you as an individual from your health information.

When we use or disclose your health care information, it may be to another organization that assists us in operating our clinics. For example, if your physician dictates a summary of his visit with you, an outside company types up the document for our medical records. We have contracted with these outside agencies, who are called "business associates," to keep any health care information received from us confidential.

  • Future Communication
    Children's Physician Group may use your name, address and phone number to contact you to provide newsletters, information about wellness programs or other services we offer.
  • Appointments
    CPG may contact you for appointments. Messages left for you will not contain specific health information.
  • Required or Permitted By Law
    CPG is required by law to disclose your health information in certain circumstances to:
    • Control or prevent a communicable disease, injury or disability, to report births and deaths, and for public health oversight activities or interventions.
    • The Food and Drug Administration, to report adverse events or product defects, to track products, to enable product recalls, or to conduct post-market surveillance as required by law.
    • A state or federal government agency to facilitate their functions.
    • Report suspected elder or child abuse to law enforcement agencies responsible to investigate or prosecute abuse.
    • Respond to a valid court order.
    • The Department of Health and Family Services, a protection or advocacy agency or law enforcement authorities investigating abuse, neglect, physical injury, death, violent crimes involving suspicious wounds, burns, gunshot wounds or death.
    • Your court-appointed guardian or an agent appointed by you under a health care power of attorney.
    • Prison officials if you are in custody.
    • Worker's Compensation officials if your injury or illness is work-related.
  • Research
    Under certain circumstances, Children's Physician Group may use and disclose your health information for research purposes. For example, a research project might compare the health and recovery of all patients who received one medication to those who received another for the same condition. For this type of project, a privacy board may waive the need for consent and any published results would not include information that identifies you. In other circumstances, you will be asked to give consent to participate in a research project. You may choose not to participate in research. Your care and treatment will not be affected by your decision.

When sharing information with others outside Children's Physician Group, we share only what is reasonably necessary unless we are sharing information to help treat you, in response to your written permission, or as the law requires. In these cases, we share all the information that you, your health care provider or the law has requested.


  • Right to Request Restrictions
    You have the right to request certain restrictions of Children's Physician Group's use or disclosure of health information for treatment, payment or health care operations. You also have the right to request a restriction on our disclosure of your health information to someone who is involved in your care or the payment for your care.

Children's Physician Group is not required to agree to your request if it interferes with patient care, treatment, clinic operations and/or payment of your bill.

If Children's Physician Group does agree to the restriction, it will comply with your request unless the information is needed to provide you with emergency treatment. A request for restriction must be made in writing. To request a restriction you must complete a request form that is available at your physician's office.

  • Right to Inspect and Copy
    You have the right to inspect and receive a copy of your health records. For copies of your health information, requests must go to your physician. For billing information, call (414) 266-6160.
  • Right to Amend
    If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information for as long as the information is maintained by Children's Physician Group. Requests for amending your health information should be made in writing to your physician. Children's Physician Group will respond to your request within 60 days after you submit the written amendment request form.
  • Right to an Accounting of Disclosures
    You have a right to request an "accounting of disclosures." This is a list of those people with whom Children's Physician Group may have shared your health information, with the exception of information shared for purposes of treatment, payment or health care operations or when you have provided us with an authorization to do so. To request an accounting of disclosures, you must submit your request in writing to your physician. We will provide the list at no cost once during each 12-month period. For any additional requests, we may charge you a fee for the cost of providing the list. We will notify you of the fee and you may choose to withdraw or modify your request at that time before any costs are incurred.
  • Right to Request Confidential Communications
    You have the right to request that we communicate with you about your health information in a certain way or at a certain location. For example, you can ask that we contact you only at work or by mail. We will accommodate all reasonable requests.
  • Right to Revoke Authorization
    Uses and disclosures of health information not covered by this Notice or the laws that apply to Children's Physician Group will be made only with your authorization. If you authorize Children's Physician Group to use or disclose your health information, you may revoke that authorization in writing at anytime. We are unable to take back any disclosures we have already made with your permission. To revoke an authorization you must contact your physician.
  • Right to Complain
    If you believe your privacy rights have been violated, you may file a complaint with Children's Physician Group or with the secretary of the Department of Health and Human Services. To file a complaint with Children's Physician Group, contact the privacy officer. All complaints must be made in writing. The privacy officer will assist you in filing your complaint and the necessary paper work. Filing a complaint will not affect your care and treatment.

Important Note: We reserve the right to revise or change this notice. Each time you sign a consent for treatment at a site covered by this notice, we will provide you with a copy of the notice in effect at that time.

Effective Date: April 14, 2003

How to Contact Us
Privacy officer: (414) 266-1773
Secretary of Department of Health and Human Services: (877) 696-6775
Financial Services: (414) 266-6160