Northwest Pediatric Therapy’s


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 (PHI)?  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


Northwest  Pediatric Therapy's

Teletherapy Consent Form

Review NWPT Privacy Policy

At Northwest Pediatric Therapy, we are committed to continuing to provide therapy for the children we serve during the COVID-19 crisis.   Teletherapy will allow our therapists to safely and effectively provide therapy to your child using a variety of telecommunication technology systems.  The following are conditions about Teletherapy at Northwest Pediatric Therapy:

1.  Teletherapy is voluntary:  you may consent or refuse that your child receive Teletherapy offered at Northwest Pediatric Therapy.

2.  If you give consent, Teletherapy will occur with your child at one location (which may be at home or another location) while their therapist is at a different site.  The therapist's site may be at Northwest Pediatric Therapy's clinic, the therapist's home, or another private site.

3.  You (or a caretaker) will be involved in some or all of your child's Teletherapy session.  A parent/caretaker must be present during the entire session.  Northwest Pediatric Therapy will not be responsible for your child's safety before, during, or after the sessions.  

4.  If a caretaker, other than yourself, is present during the session, they must abide to the confidentiality of your child's therapy session and any information obtained during the session. 

5.  You are soley responsible for the technology used with your child during the session.  This includes, but is not limited to the computer system, iPad, phone, WIFI system, cellular data, electricity, any supplies/material/toys used, and all charges associated with these items.  

6.  If the video/audio connections are not adequate (interruptions/technical difficulties), the session may be discontinued by you or your child's therapist.  In addition, a Teletherapy session may be discontinued early by you or your child's therapist for any reason.  In the event that a Teletherapy session is ended early, your child's therapist may suggest rescheduling the session for a later date/time during that week.  

7.  Your child's Teletherapy schedule will be made according to your preferences as much as possible.  However, your child's therapist will also be scheduling other children and will be trying to accommodate your family's schedule as well as other family's schedules.  

8.  You are responsible for contacting your child's insurance/funding source to determine if Teletherapy is covered for your child's therapy.  If your insurance denies coverage for Teletherapy when Northwest Pediatric Therapy bills them, you will be responsible for a private payment of Teletherapy services.        

9.  Teletherapy will be provided for the amount of time as agreed upon by you and Northwest Pediatric Therapy but no longer than what your child's insurance/funding will allow, and/or when the clinic at Northwest Pediatric Therapy reopens.  Your child's therapy schedule at the clinic will be the same as it was prior to the implementation of Teletherapy.

10.  You understand that if your child has any type of state funding (Medicaid, AR Kids, TEFRA, or PASSE: AR Total Care, Summit Community Care, Empower) they will be allowed to receive up to 90 minutes a week of Teletherapy (but no more than what your child's Prior Authorization already allows).  Evaluations and re-evaluations cannot occur with Teletherapy, however, it is our understanding that an evaluation that expires will be given an automatic 30 day extension during the use of Teletherapy.

11.  If you need to file a complaint regarding your child's Teletherapy experience, you should contact Mrs. Lynn by email at

12.  You agree you have been given access to Northwest Pediatric Therapy's Privacy Policy (see link at top of page).


*Please note that "Parent's Signature" in the box below is only to indicate the parent/guardian who is completing this form.  You will specifically sign later in this waiver to allow or deny Teletherapy for your child. 



First Parent's Name

First Name*

Last Name*
First Parent's Date of Birth*
I certify that I am 18 years of age or older
First Parent's Signature*
Second Parent's Name

First Name*

Last Name*
Second Parent's Date of Birth*
Third Parent's Name

First Name*

Last Name*
Third Parent's Date of Birth*
Fourth Parent's Name

First Name*

Last Name*
Fourth Parent's Date of Birth*
Fifth Parent's Name

First Name*

Last Name*
Fifth Parent's Date of Birth*
Sixth Parent's Name

First Name*

Last Name*
Sixth Parent's Date of Birth*
Seventh Parent's Name

First Name*

Last Name*
Seventh Parent's Date of Birth*
Eighth Parent's Name

First Name*

Last Name*
Eighth Parent's Date of Birth*
Ninth Parent's Name

First Name*

Last Name*
Ninth Parent's Date of Birth*
Tenth Parent's Name

First Name*

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


Confirm Email*

Child's First Name *

Child's Last Name *

Child's Date of Birth *

TODAY'S date *

Phone number of parent/guardian completing Telehealth Consent Form *
By signing below, I agree to allow my child to receive Teletherapy from Northwest Pediatric Therapy.

Please type your name if you give permission to Northwest Pediatric Therapy to provide Teletherapy to your child.
REFUSAL OF TELETHERAPY: By signing below, I understand that I have been given all of the details of Teletherapy and understand that Northwest Pediatric Therapy is providing me with the facts about Teletherapy services to the best of their knowledge. I also understand that Teletherapy will be the only means of therapy until Northwest Pediatric Therapy decides it is safe for patients, families, therapists, and staff to return to NWPT's clinic.

Please type your name ONLY for the REFUSAL of Teletherapy
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*
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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