NOTICE OF PRIVACY PRACTICES 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. Please review it carefully.  If you have any questions about this notice or if you need more information, please contact our Privacy Officer.

Privacy Officer/Northwest Pediatric Therapy:  Lynn Center
Mailing Address: 2580 East Joyce Blvd Ste 12, Fayetteville, AR 72703  
Phone: (479) 521-7337 

About This Notice
This notice of Privacy Practices Describes how Northwest Pediatric Therapy may use or disclose your child’s medical information with and without your consent, how we may contact you regarding your child’s medical information, and your rights with respect to your child’s protected health information. We are also required by law under the Health Information Portability and Accountability Act (HIPAA) to maintain the privacy of your child’s protected health information (PHI). 

What is Protected Health Information?  Protected Health Information (PHI) is information that individually identifies your child and that we create or get from you or from another health care provider, a health plan, your employer, or a health care clearinghouse and that relates to (1) your child’s past, present, or future physical or mental health or conditions, (2) the provisions of health care to your child, or (3) the past, present, or future payment of your child’s health care.

How We May Use and Disclose Your Child’s PHI:  

Treatment: We may use your child’s PHI to give medical treatment or services and to manage and coordinate medical care. For example, we may disclose PHI to therapists and other personal who are involved in your child’s treatment, including people outside our practice, such as referring to specialists and physicians.

Payment: We may use and disclose PHI so that we can bill for the treatment and services received from Northwest Pediatric Therapy, to submit a claim to your insurance carrier and/or state funding sources for payment. 

Health Care Operations: HealthCare Operations include activities performed by our clinic , such as quality assessment, case management/coordination, training programs for supervisory purpose, and activities associated with the licensing and issuance of credentials of our staff.

As Required by Law: We will disclose PHI about your child when required to do so by international, federal, state, or local law. 

To Avert a Serious Threat to Health or Safety: We may use and disclose PHI when necessary to prevent a serious threat to your child’s health or safety or to the health and safety of others, but we will only disclosure the information to someone who may be able to help prevent the threat. 

Business Associates: We may disclose PHI to our business associates who perform functions on our behalf or provide us with services if the PHI is necessary for those functions or services. For example, we may use another company to do our billing or to provide transcription or consulting services for us. All of our business associates are obligated, under contract with us, to protect the privacy of your child’s PHI.

Health Oversight Activities: We may disclose PHI to health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure, and similar activities that are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.  

Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we my disclose PHI in response to a court or administrative order. We also may disclose PHI in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. We may also use or disclose your PHI to defend ourselves if you are to sue us.

Law Enforcement: We may release PHI if asked by a law enforcement official for the following reasons: in response to a court order, subpoena, warrant, summons or similar processes; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime if; about a death we believe may be a result of criminal conduct; about criminal conduct on our premises; and in emergency circumstances to report a crime, the location of the crime or victims, or the identity , description, or location of the person who committed the crime. 

National Security: We may release PHI to authorize federal offices for national security activities authorized by law. We may release PHI to a coroner, medical examiner, or funeral director so that they can carry out their duties. 

Contacting You: Northwest Pediatric Therapy may use and disclose PHI to contact you to remind you that your child has an appointment for medical care, or to contact you to tell you about possible treatment options or alternatives or health related benefits and services that may be of interest to you. Appointment reminders may be made by phone, email, or phone texts. 

If you do NOT wish that a message be left on your answering machine, you do NOT wish to receive mail at your residence, you do NOT wish to receive information by email, or you do NOT wish to receive texts via your phone, please contact the Privacy Officer. 

Disclosure to Others: You will be asked to sign an authorization if you ask to have Northwest Pediatric Therapy disclose your protected health information to others when it is for something other than payment, treatment, or other health care operations. 
Individuals Involved in Your Child’s Care or Payment for Your Child’s 

Care: We may disclose PHI to a person who is involved in your child’s medical care or helps pay for your child’s care, such as a family member or friend, to the extent it is relevant to that person’s involvement in your child’s care or payment related to your child’s care.

Your Written Authorization is Required for Other Uses and Disclosures:  Uses and disclosures for marketing purposes and disclosures that constitute a scale of PHI can only be made with your written authorization.  Other uses and disclosures of PHI not covered by this notice of the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer, and we will no longer disclose PHI under the authorization. Disclosures that we made before you revoked the authorization will not be affected by the revocation. 

YOUR RIGHTS: You have the following rights, subject to certain limitations, regarding your child’s PHI:

Right to Inspect and Copy: You have the right to inspect and/ or request a copy of your child’s protected health information. This Information will be given to you within one week of your request. However, this does not include information complied in anticipation of, or use in a civil, criminal, or administrative action proceeding. 

Request a Restriction: You have the right to request a restriction of your child’s protected health information. You may ask us not to use of disclose any part of your child’s protected health information for the purpose of treatment, payment, or health care operations. You may also request restriction on specific health information to not be disclosed to family members/friends who may be involved in your care. Please discuss any restriction you wish to request with the Privacy Officer.

Alternative Communication Means: You have the right to receive confidential communication from us by alternative means or at an alternative location. You must specify in writing, to the Privacy Officer, the alternative method and /or location where you wish to be contacted. We will accommodate reasonable requests. In determining whether a request is reasonable, we will consider the administrative difficulty it takes to complete the request.

Right to Request Amendments: You have the right to amend your child’s protected health information with the Privacy Officer. You may request an amendment of protected health information about your child for as long as we maintain this information. However, the law limits your ability to change or add to your health information. 

Receive an Accounting of Disclosers: You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to be made directly to you, family members, or friends involved  in your child’s case. The right to receive this information may be subject to certain expectations.

Right to Receive Notice of a Breach: We are required to notify you by first class mail or by e-mail (if you have indicated a preference to receive information by e-mail), of any breach of your unsecured PHI.

Right to an Electronic Copy of Electronic Medical Records: If your child’s PHI is maintained in one or more designated record sets electronically (for example an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your child’s record be given to you or transmitted to another individual or entity. If you chose to have your PHI transmitted electronically, you will need to provide a written request to this office listing the contact information of the individual or entity who should receive your child’s electronic PHI.

Right to Restrict Certain Disclosures to Your Health Plan: You have the right to restrict certain disclosures of PHI to a health plan if the disclosure is for payment or health care operations and pertains to a health care item or service for which you have paid out of pocket in full. We will honor this request unless we are otherwise required by law to disclose this information. This request must be made, in writing, at the time of service. 

Right to Request Confidential Communications: You have the right to request that we communicate with you only in certain ways to preserve your child’s privacy. For example, you may request that we contact you by mail at a special address or call you only at your work number. You must make any such request in writing and you must specify how or where we are to contact you. We will accommodate all reasonable requests. We will not ask you the reason for your request. 

Copy of this Notice: You have the right to obtain a paper copy or emailed copy of this notice from us, upon request to the Privacy Officer, your child’s therapist, or the office administrator.  

How to Exercise Your Rights Required In Writing:  To exercise your rights described in this Notice, send your request, in writing, to our Privacy Officer, Lynn Center,  at 2580 East Joyce Blvd, Ste 12, Fayetteville, AR  72703.                           

Rev. 2019

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Northwest Pediatric Therapy

Located in the "Joyce Medical and Professional Center"

2580 East Joyce Blvd, Ste 12

Fayetteville, AR 72703

Phone: (479) 521-7337, Fax: (479) 521-7338

Email: nwpediatrictherapy@sbcglobal.net

Facebook:  www.facebook.com/nwpedtherapy


Review NWPT's Privacy Policy

Welcome to Northwest  Pediatric Therapy!  

If you should have any questions completing this form, please contact our clinic by phone at (479) 521-7337 or by email at nwpediatrictherapy@sbcglobal.net.

You will need your INSURANCE CARD / INFORMATION when you complete this form.

Please COMPLETELY FINISH THIS FORM BEFORE EXITING as the information you provided will NOT be saved until you finish the form, give your electronic signature consent, and agree to the document. You do not have to print this form.  Once you complete online, it will be sent electronically back to NWPT.

Thank you for allowing us to provide speech-language therapy, occupational therapy, and/or developmental therapy services to your child!

First Parent/Guardian Name

First Name*

Last Name*

Phone*
First Parent/Guardian Date of Birth*
I certify that I am 18 years of age or older
First Parent/Guardian Signature*
Second Parent/Guardian Name

First Name*

Last Name*
Second Parent/Guardian Date of Birth*
Third Parent/Guardian Name

First Name*

Last Name*
Third Parent/Guardian Date of Birth*
Fourth Parent/Guardian Name

First Name*

Last Name*
Fourth Parent/Guardian Date of Birth*
Fifth Parent/Guardian Name

First Name*

Last Name*
Fifth Parent/Guardian Date of Birth*
Sixth Parent/Guardian Name

First Name*

Last Name*
Sixth Parent/Guardian Date of Birth*
Seventh Parent/Guardian Name

First Name*

Last Name*
Seventh Parent/Guardian Date of Birth*
Eighth Parent/Guardian Name

First Name*

Last Name*
Eighth Parent/Guardian Date of Birth*
Ninth Parent/Guardian Name

First Name*

Last Name*
Ninth Parent/Guardian Date of Birth*
Tenth Parent/Guardian Name

First Name*

Last Name*
Tenth Parent/Guardian Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
DEMOGRAPHIC INFORMATION

TODAY'S DATE *

ABOUT YOUR CHILD


Child's FIRST and LAST Name *

Child's Birthdate *

Child's age

Child's Social Security Number

Please explain your concern regarding your child's development: *
Does your child have any allergies?*
No
Yes

If yes, please list all allergies below:
Is your child currently taking any medications?*
No
Yes

If yes, please list all medications:
Are immunizations current? *
Yes
No
My child does not receive immunizations

PARENT CONTACT INFORMATION


Mother's name *

Father's name *

Address Line 1: Street Address, P.O. box, etc. *

Address Line 2: Apartment number, building, floor, etc.

City *

State *

Zip/Postal Code *

Home phone number (list "none" if not applicable)

Mother's cell phone number *
Participate in texting?*
No
Yes
In addition, should we ever need to contact you by phone, do you give us permission to leave a voicemail?*
No
Yes

Father's cell phone number *
Participate in texting?*
No
Yes
In addition, should we ever need to contact you by phone, do you give us permission to leave a voicemail?*
No
Yes

Preferred email address: *

Mother's Occupation

Father's Occupation

Emergency Contact Name

Emergency Contact Phone Number

What is this person's relationship to your child? (For example: grandparent, aunt, friend of family)

PRIMARY CARE PHYSICIAN / MEDICAL INFORMATION 


Child's Primary Diagnosis (if applicable)

Child's Secondary Diagnosis (if applicable)

Primary Care Physician / Doctor *

Clinic Name

Clinic Phone Number

PLEASE COMPLETE THE FOLLOWING:

Gender:*
Male
Female
Ethnicity:*
African American
East Asian or Asian American
Latino or Hispanic American
Middle Eastern or Arab American
Native American
White or Euro-American
South Asian or Indian American
Other

Primary language spoken in the home *

Secondary language spoken in home (if applicable)
INSURANCE INFORMATION

IF YOUR CHILD RECEIVES ANY OF THE FOLLOWING STATE FUNDING, PLEASE LIST THEIR FUNDING NUMBER IN THE APPROPRIATE BOX BELOW:


Medicaid Number

TEFRA Number

AR Kids A Number

AR Kids B Number

PRIMARY INSURANCE INFORMATION

DOES YOUR CHILD HAVE A PRIMARY INSURANCE?*
No
Yes

INSURANCE NAME

POLICY NUMBER

GROUP NUMBER

INSURED'S NAME

INSURED'S DATE OF BIRTH

INSURED'S PLACE OF EMPLOYMENT

SECONDARY INSURANCE INFORMATION

DOES YOUR CHILD HAVE A SECONDARY INSURANCE?*
No
Yes

INSURANCE NAME

POLICY NUMBER

GROUP NUMBER

INSURED'S NAME

INSURED'S DATE OF BIRTH

INSURED'S PLACE OF EMPLOYMENT
Please attach a copy of the FRONT of ALL your child's insurance card(s) here.
  
Front of Insurance card(s)
Valid file types: JPG, GIF, PNG, and PDF
AUTHORIZATIONS

Please complete the following by checking the appropriate box for each authorization

AUTHORIZATION FOR EVALUATION AND TREATMENT OF MY CHILD

I authorize Northwest Pediatric Therapy to evaluate and treat my child as recommended by my child's primary care physician. *
I agree
I DO NOT agree

AUTHORIZATION TO RECEIVE TELETHERAPY SERVICES

In the event that your child cannot attend in-person therapy services due to COVID-19 or inclement weather, your child may be eligible to receive teletherapy services, depending on your insurance plan.*
I agree
I DO NOT agree

AUTHORIZATION TO BILL, RECEIVE PAYMENT, AND FINANCIAL RESPONSIBILITY

I authorize Northwest Pediatric Therapy to bill my child's insurance(s) for services rendered. I authorize payment of medical benefits to be made directly to Northwest Pediatric Therapy for services rendered. I agree to either pay in full or set up a payment plan and begin payment for all charges within 7 days of the receipt of the billed services. I agree to be fully responsible for my insurance deductible, co-pay, coinsurance, and/or the full payment if my insurance denies coverage. *
I agree
I DO NOT agree

AUTHORIZATION TO REQUEST AND RECEIVE MEDICAL RECORDS 

I authorize Northwest Pediatric Therapy to request and receive my child's medical records for any purpose deemed necessary as related to my child's treatment. This includes, but is not limited to, referrals for evaluations and treatment, hearing evaluation results, swallow study results, etc. *
I agree
I DO NOT agree

LIFE SAVING CONSENT (if parent is not present)

If I, the legal parent/guardian, cannot be reached, I authorize the administration of "life saving" procedures such as x-rays, surgery, transportation, hospitalization, medication, and/or any treatment procedure deemed necessary by a medical professional. If you do not agree to this, then we require that you do not leave the clinic during your child's therapy session. *
I agree
I DO NOT agree

AUTHORIZATION TO PHOTOGRAPH/VIDEO FOR PROMOTIONAL USE

I give Northwest Pediatric Therapy (NWPT) the right and privilege to photograph/video my child for the use of developing and publicly releasing promotional information. I understand that my child's image may be viewed in photos in the clinic, in magazines, flyers, brochures, on television, on NWPT's website, or on NWPT's Facebook page. *
I agree
I DO NOT agree

AUTHORIZATION TO POST PHOTOGRAPHS DURING SPECIAL EVENTS AT NORTHWEST PEDIATRIC THERAPY 

I give Northwest Pediatric Therapy the right and privilege to photograph/video my child during Special Events such as Kid of the Week, Water Week, Holidays, Child's Graduation, etc. and post these photos on NWPT's Facebook and/or Instagram. *
I agree
I DO NOT agree

ATTENDANCE POLICY 

I understand that Northwest Pediatric Therapy has an attendance policy and that after my child receives 4 ATTENDANCE NOTICES regarding No Shows, tardiness, or inconsistent attendance, my child may be discharged from therapy. *
I agree

CONSENT FOR CHILD OBSERVATION AND INTERN/STUDENT INTERACTION 

I understand that Northwest Pediatric Therapy is a teaching facility. I understand that my child may be observed through supervised observations undertaken as part of an academic internship, practicum, and/or observation requirement for students. They may participate in activities with my child while his/her therapist is under direct supervision. I understand that each student will be required to abide by Northwest Pediatric Therapy's Privacy Practices. *
I agree

ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES 

I have been offered a copy of Northwest Pediatric Therapy's Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide Lynn M. Center, INC. (dba: Northwest Pediatric Therapy) with my authorization and consent to use and disclose my protected health care information for the purpose of treatment, payment, and health care operations as described in the Privacy Notice. *
I agree

Typing your name will represent your signature that you acknowledge our privacy policy and your rights. *

ACKNOWLEDGMENT OF NORTHWEST PEDIATRIC THERAPY'S HANDBOOK RULES AND GUIDELINES

I acknowledge that I have been told about, given, or offered a copy of Northwest Pediatric Therapy's "Welcome Handbook" that is located in the waiting area of the clinic. I also commit to read AND abide by each of Northwest Pediatric Therapy's Rules/Guidelines in this notebook. *
I agree

AUTHORIZATION FOR TRANSPORTATION RELEASE 


For the safety of your child, please list anyone who is authorized to pick your child up from therapy. If you need to remove a name from the list at any time in the future, you must contact clinic staff at (479) 521-7337. Please be aware that anyone other than the parent or legal guardian will be asked to show a form of picture identification.
THERAPY AND SCHOOL INFORMATION
Does your child currently receive other therapies?*
No
Yes
If YES, please check the therapy he/she currently receives:
Speech Therapy
Physical Therapy
Occupational Therapy
Developmental Therapy
Other
My child has been evaluated but has not started therapy

If YES to any of the above, please list the therapy type, therapist's name, clinic's name, and the day(s) and time(s):
May we contact your child's other therapist(s) to coordinate services?*
No
Yes
Not applicable

If YES, please list your child's therapist, the therapy provided, and the phone number the therapist can be contacted at best:
Does your child currently attend preschool/daycare or school?*
No
Yes

If YES, please list where and the days/times your child attends:
Other than preschool/daycare, does your child get to socialize with other children in the community (library, playdates, at the park, etc)?*
No
Yes

If YES, please explain:

SCHEDULING 

If your child DOES qualify for therapy once he/she is evaluated, please check the days and times that would be best for your child to attend therapy. Please check at least one box on each day.

MONDAY *
early morning (8:30-12:30)
mid-afternoon (1:30-3:30)
late-afternoon (3:30-5:30)
Not Available
TUESDAY *
early morning (8:30-12:30)
mid-afternoon (1:30-3:30)
late-afternoon (3:30-5:30)
Not Available
WEDNESDAY *
early morning (8:30-12:30)
mid-afternoon (1:30-3:30)
late-afternoon (3:30-5:30)
Not Available
THURSDAY *
early morning (8:30-12:30)
mid-afternoon (1:30-3:30)
late-afternoon (3:30-5:30)
Not Available
FRIDAY *
early morning (8:30-12:30)
mid-afternoon (1:30-3:30)
late-afternoon (3:30-5:30)
Not Available

What time does your child usually nap during the day?

Special request/comment on scheduling:
MEDICAL/DEVELOPMENTAL HISTORY

PREGNANCY AND DELIVERY

Did you experience any of the following during pregnancy? Please check all that apply:
Illness
Injury
Anemia
Bleeding
Operations
Smoking
Illegal Drug Use
Alcohol Use
Prescription Drug Use
Other

If you checked any of the above, please explain:
Method of delivery: *
Vaginal
Cesarean
Breech
Unknown
Were any of the following used?
Forceps
Vacuum Extractor
Unknown
Were any medications given?*
No
Yes
Unknown

If medications were given, please list:
Were there any complications?*
No
Yes
Unknown

If yes, please explain:

BIRTH AND INFANT HISTORY


List weeks of gestation at birth *

What was your newborn's weight? (pounds, ounces) *

What was the APGAR Score?
Did your child pass his/her newborn hearing screening at birth?*
Passed
Failed

If failed, please explain
Please check if any of the following occurred following delivery:
Jaundice
Blood Transfusion
Limpness
Lack of oxygen
Congenital Defect
Other
Failed his/her newborn hearing screening
Lengthy stay in the hospital
Hospitalization soon after birth

If YES to any of the above, please explain in further detail:

If your child was adopted, please list age of adoption and country of adoption:

MEDICAL HISTORY

Please check if your child has experienced any of the following: *
Meningitis
Measles/Mumps
Chicken Pox
Tuberculosis
Polio
Scarlet Fever
High Fevers
Seizures/Convulsions
Diabetes
Heart Problems
Physical Injuries
Lung/Bronchial difficulties
Asthma
Pneumonia
Tonsillectomy
Sleeping problems
Indoor/Outdoor allergies
Food/Medication allergies
Other allergies
Vision difficulties
Frequent ear infections
Tubes in ears
Hearing loss
Other
None of the above

If YES to any of the above, please list details:
Are you concerned about your child's hearing?*
No
Yes

If YES, please explain:

What were the results of your child's last hearing test? (if applicable)

When was this hearing test performed?

DEVELOPMENTAL HISTORY

Please check if your child has difficulty with any of the following:
Difficulty using beginning words, phrases, and/or sentences
Difficulty understanding what you say
Difficulty using clear, understandable speech
Loss of words
Inconsistently responds to sounds/voices
Difficulty making eye contact
Not interested in socializing with other children
Difficulty paying attention
Difficulty learning in school
Difficulty dressing independently
Difficulty feeding self independently
Difficulty putting together puzzles
Difficulty sitting independently
Difficulty learning to crawl/walk
Difficulty running/jumping/hopping
Demonstrate abnormal behaviors
Avoids touching certain textures
Avoids eating certain textures of foods
Recent changes at home
Difficulty coloring, tracing, drawing, and/or copying shapes
Difficulty transitioning between environments & activities
Frequent meltdowns
Gets emotional easily when feelings get hurt or when physicially gets hurt
Seeks out movement, jumping, crashing, rough-housing
Overly sensitive to touch, sound, smell, or movement
Hyperactive or low energy (props on furniture or always leans)

If you checked any of the above, please explain:

If your child uses a limited number of words (LESS than 20), please list all words your child is using on a daily basis:

FEEDING/EATING SKILLS

Are you concerned regarding your child's feeding skills?*
No
Yes
Please check if any of the following apply to your child:
Problems breastfeeding
Difficulty drinking from a bottle
History of reflux
Received medications for reflux
Difficulty transitioning to solid food
Does not eat well for his/her age
Difficulty using pacifier
Difficulty drinking from straw
Difficulty drinking from cup
Experiences fussiness after eating
Avoids eating certain foods
Vomits after eating
Only eats certain foods
Child's weight and height are NOT normal for his/her age
Refuses to sit in chair during meals
Has failed a Video-Swallow study or Gastrointestinal Series
Other

If you checked any of the above, please explain:

Please list any other medical/developmental information or regarding your child that was not previously covered:

FAMILY HISTORY 

Please check if any immediate family members have experienced the following: (Immediate family members include, Mother, Father, Siblings, Grandparents, Aunts, Uncles, Cousins)
ADD/ADHD
Autism
Bipolar Disorder
Obsessive/compulsiveness
Anxiety Disorder
Learning Disorder
Hearing Loss
Stuttering
Other speech disorders
Genetic Disorder
Sensory/Processing Dysfunction Disorders
Other

Please list all family members living in the home, their relationship to your child, and their age: (FOR EXAMPLE: Abigail, sister, 8)

During the day of the evaluation, please provide your child's 

INSURANCE CARD to the front desk so that a copy can be made.  

Thank you!

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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