If your child has a
life-threatening emergency,
call 911 immediately.

Call the Main Line for
Appointments, Urgent Issues
and Triage Nurse

Fax: 952-401-8242
An EEO/AA Employer

Privacy Policy

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

During treatment at South Lake Pediatrics, doctors, nurses, 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.

Many patients of South Lake Pediatrics are children. When we refer to "you" or "your" in this Notice, we refer to the patient. When we refer to types of disclosures of information to "you", we mean disclosures 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 the patient’s 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 South Lake Pediatrics. For example, we may use or disclose information for quality assurance activities.
  • Fundraising/Marketing/Sale of PHI: South Lake Pediatrics does not participate with any of these at this time. However, if this changes any time in the future, we will make a good faith effort to obtain your consent or refusal to participate.
  • Business Associates: Some services are provided by or to South Lake Pediatrics through contracts with business associates. Examples include South Lake Pediatrics’ attorneys, consultants, collection agencies and accreditation organizations. We may disclose information about you to our business associate so that they can perform the job we have contracted with them to do. To protect the information that is disclosed, each business associate is required to sign an agreement to appropriately safeguard the information and not to redisclose the information unless specifically permitted by law.
  • Appointment reminders and other health information: We may use information to send you reminders about future appointments. Information may be used to provide you with information about new or alternative treatments or other health care services that may be of interest to you.
  • Family members or other responsible people: We may disclose information to people who will be taking care of the patient or are responsible for paying bills, such as other family members. South Lake Pediatrics 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 the patient is and what their general medical condition is. If the patient is able to make his or her own health care decisions, South Lake Pediatrics will ask permission before using medical information for these purposes. If the patient is unable to make health care decisions, South Lake Pediatrics 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 the patient.
  • 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: South Lake Pediatrics 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 workers’ compensation purposes.
  • Research: Federal law permits South Lake Pediatrics 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 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 research study, as required by law, prior to releasing any identifiable information about you to outside researchers.

South Lake Pediatrics will not use or disclose medical information in any other way unless you allow us to do so in writing. If you do give us permission to use or disclose the patient’s medical information for another purpose, you have the right to change your mind and revoke the permission at any time.

Privacy rights

  • Restrict use and disclosure: You may request that South Lake Pediatrics not use medical information in certain ways or for certain purposes. You may also request that South Lake Pediatrics not provide medical information to certain people. However, South Lake Pediatrics has the right to refuse your request. South Lake Pediatrics may use or disclose the patient’s medical information in situations requiring emergency treatment, in which case we will ask the person(s) who receive the information not to further use or disclose the information.
  • Provide confidentiality: You may request that South Lake Pediatrics 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 the patient’s 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 the patient’s 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 after April 14, 2009.
  • 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 Humans Services and/or with the South Lake Pediatrics privacy official listed below. Filing a complaint will not affect the quality of the services you receive from South Lake Pediatrics and you will not be retaliated against for filing a complaint.
    The U.S. Department of Health and Human Services
    200 Independence Avenue S.W.
    Washington, D.C. 20201
    (202) 619-0257
    Toll free: 1-877-696-6775  
  • South Lake Pediatrics privacy official: You may contact the designated privacy official at
    South Lake Pediatrics:
    Health Information Supervisor
    17705 Hutchins Drive #250
    Minnetonka, MN 55345
    (952) 401-8300
    (952) 401-8242 Fax

The effective date of this notice is April 14, 2003 and updated September 23, 2013. South Lake Pediatrics 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. South Lake Pediatrics is required to abide by the terms of the notice currently in effect. South Lake Pediatrics reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information maintained by South Lake Pediatrics. If the terms of this notice are changed, South Lake Pediatrics will provide individuals with a revised notice: at the time of treatment, or upon request, by posting the revised notice in designated locations at South Lake Pediatrics.

Protection of Your Identity Is Important to South Lake Pediatrics

South Lake Pediatrics has always been careful to make sure your private information is kept confidential and secure.

In response to a new law insured by the Federal Trade Commission (FTC), called the Red Flags Rule, South Lake Pediatrics has developed an identity theft prevention program to increase your security and to further protect your information.

Beginning May 1, 2010, you will be asked to provide two forms of identification each time you come to any of our clinics for services. This verification will help assist in preventing identity theft in our communities. Please know your patient care will not be delayed due to a lack of identification.

If you have questions about this process, or think that your identity may have been stolen, contact South Lake Pediatrics by contacting our Patient Account Services Department: 952-401-8282.


Updated 9/23/13