Diocese of La Crosse : : : Natural Family Planning Online Registration

Woman's Information
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Man's Information
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Class Option & Payment
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NFP Online Course ($110.00)

Couple Information:
Single
Engaged, wedding date
Married

Referred to NFP by (check all that apply):
Advertising	Healthcare
Marriage Prep	NFP Personnel
Church	Others
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*Call Northwest Family Services for information about payment plans. After we have received your payment, we will send you a confirmation notification. If you are signing up for the online course, we will email you your logon and access code and you will be sent your packet of materials by mail within 10 business days. If you are signing up for the correspondence course, your packet will be sent within 10 business days.

Privacy Agreement Notice of Privacy Practices for Northwest Family Services (NWFS) This Notice is effective April 14, 2003 Because you are participating in an on-line Natural Family Planning (NFP) class and the information being transmitted electronically contains what is considered protected health information, Northwest Family Services (NWFS) is required to provide you with this Notice of Privacy Practices under the federal Health Insurance Portability and Accountability Act (HIPAA). NWFS is required to: - Maintain the privacy of your protected health information. - Provide this Notice of our legal duties and privacy practices for use and disclosure of your protected health information. - Follow the terms of this Notice. - Communicate any changes in this Notice to you. For more information about HIPAA, see http://www.hhs.gov/ocr/hipaa/ This Notice describes how we may use or disclose your protected health information, with whom that information may be shared, and the safeguards we have in place to protect it. The Notice also describes your right to approve or refuse the release of specific information, except when the release is required or authorized by law. We reserve the right to change this Notice. We reserve the right to make the changed Notice effective for health information we already have, as well as any information we receive in the future. If we change the Notice, the changed notice will be posted on our web site, available in our office, and mailed, as appropriate. We will provide you with an Acknowledgment and Consent by which you can acknowledge your receipt of this Notice and consent to our use and disclosure of protected health information as described in the Notice. Our intention is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. Our provision of services will not be conditioned upon your signing the Acknowledgment and Consent. If you decline, we will continue to provide you with education and will use and disclose your protected health information for education, payment, and health care operations when necessary. How We May Use Your Protected Health Information We will use and disclose your protected health information to provide, coordinate, and manage your NFP instruction. The sharing of health information for instructional purposes may progress to others involved in your education. For example, our office staff may be asked to mail you materials specific to your circumstances. In addition to communicating with you at class, we may need to contact you from time to time. To communicate with you regarding your education, we will use the names, addresses (street and email), telephone numbers (land line for home and office, cellular telephone, facsimile) and other contact information you provide to us. We will assume that when using the information you provide, we may leave messages on answering systems at those numbers, send facsimiles, and send mail and email without calling first to confirm your presence at the machine at the receiving end or confirming your exclusive use of the address. For instance, we might leave a message on your home answering machine to confirm your follow up appointment or send a letter with a review of charting information you have provided. When doing so, we are always required to use our best judgment and comply with all applicable privacy and other laws regarding the manner and type of disclosure under the circumstances. You may request that we communicate with you using alternative means or an alternate location. We will not ask you the reason for your request. We will accommodate reasonable requests, when possible. Payment Your protected health information will be used, as needed to obtain payment for your educational services. We will use and disclose protected health information when we send bills for services to you, often with accompanying documentation and information that identifies you, the services in which you are participating, and materials received. Educational Services Operations We may use or disclose, as needed, your protected health information to provide NFP instruction. These activities include but are not limited to performing quality assessments, oversight, and staff reviews, training of NFP Providers, and conducting or arranging for other educational activities. We may use or disclose your protected health information to remind you of your appointment or to provide you with health information of interest. Individuals Involved in Your Health Education Unless you object, we may disclose to a member of your spouse, relative, or other person you identify to us, your protected health information that is related directly to that person=s involvement in your education. We may also give protected health information to someone who helps pay for your education. For example, if a husband calls with questions about his wife=s chart, we will answer his questions. Your Rights Regarding Your Health Information You may exercise the following rights by submitting a written request by mail to the Privacy Officer of NWFS at the address listed under Contact Information below. Please be aware that we are not required to agree to, and might deny, your request. You may, however, seek a review of the denial. Right to Inspect and Copy You may inspect and obtain a copy of your protected health information that we maintain for as long as we maintain the protected health information. This includes educational records and any other records we use in offering health education to you. You have the right to request the information in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $1 for each page and $40 per hour for staff time to locate and copy your health information and postage at cost, if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for more information. Right to Request Restrictions You may ask us not to use or disclose any part of your protected health information for education, payment, or operations. Your request must be made in writing by mail to the Privacy Officer. In your request, you must tell us (1) what information you want restricted, (2) whether you want to restrict our use, disclosure, or both, (3) to whom you want the restriction to apply, and (4) an expiration date. If we believe that the restriction is not in the best interest of either party, or we cannot reasonably accommodate the request, we are not required to agree. If the restriction is mutually agreed upon, we will not use or disclose your protected health information in violation of that restriction unless it is needed to provide urgent services. You may revoke a previously agreed upon restriction at any time, in writing. Right to Request Alternate Communications You may request that we communicate with you using alternative means or an alternate location. We will not ask you the reason for your request. We will accommodate requests, when possible. Right to Request Amendment If you believe the information we have about you is incorrect or incomplete, you may request an amendment to your protected health information as long as we maintain this information. While we will accept request for amendment, we are not required to agree to an amendment. Right to an Accounting of Disclosures You may request that we provide you with an accounting of the disclosures we have made of your protected health information. This right applies to disclosures made for purposes other than education, payment, or operations. The disclosure must have been made after April 14, 2003 and no more than six years from the date of the request. This right excludes disclosures made to you or to family members or friends involved in your care. The right to receive this information is subject to additional exceptions, restrictions, and limitations. Right to Obtain Paper Copy of this Notice You may obtain a paper copy of our Notice of Privacy Practices by contacting the Privacy Officer at the addresses or number listed below and requesting that a copy be mailed to you. Complaints If you believe your privacy rights have been violated, you may file a written complaint with our Privacy Officer or the Secretary of the United States Department of Health and Human Services in Washington, D.C. No retaliation will occur against you for filing a complaint. Contact Information Privacy Officer Northwest Family Services 6200 SE King Road Portland, Oregon 97222 503-546-6377 ACKNOWLEDGMENT AND CONSENT REGARDING NOTICE OF PRIVACY PRACTICES PLEASE READ CAREFULLY BEFORE SUBMITTING I acknowledge receipt of the Notice of Privacy Practices of Northwest Family Services (NWFS), which provides information about how NWFS may use and disclose my protected health information. The Notice of Privacy Practices states that NWFS reserves the right to change its terms. Should this happen, I understand that NWFS will make the changed Notice available to me on its web site, in its offices, and by mail, as appropriate. I have the right to revoke this consent, in writing, except where NWFS has already made disclosures in reliance on my prior consent. I understand that I have the right to request restrictions on how my protected health information may be used or disclosed for education, payment, and educational operations. NWFS is not required to agree to my restrictions, but if it does, it is bound by its agreement with me. By signing below, I consent to the use and disclosure of my protected health information for education, payment, and educational operations as described in the Notice of Privacy Practices. I specifically consent to NWFS communicating with me using the contact information I provide, as further described in the Notice of Privacy Practices. I have read and agree to the terms of the privacy agreement

Client Consent Form I/we, agree to be a participant(s) in the Northwest Family Services' Natural Family Planning client instruction program. I/we understand that the practice of NFP is completely voluntary, even if attendance in the class series is a requirement for your marriage preparation program. The nature and purpose of the program and the effectiveness of the method have been fully explained to me. I acknowledge that no assurance has been made to me as to the results that may be obtained. It is also understood that no method of Natural Family Planning is 100% effective. We are aware of the importance of completing the course, including the learning activities, reading and charting homework, and following the recommendations of the instructor. We accept full responsibility for learning and application of the method and for contacting our instructor or the Northwest Family Services as needed. I have read and agree to the terms of the consent form

Course Duration: Clients will have 120 days access to the course. That time begins when your package is mailed. If you do not complete the course within 120 days, you will need to pay a $10.00 readmit fee to get access for another 30 days.

Return/Refund Policy Products: All unopened items (excluding bulk orders) in new condition may be returned within 30 days for either a refund or exchange. Shipping charges are not refundable. There is a $10 restocking fee per return. Bulk orders are not returnable. Services: Individuals requesting refund prior to a class hosted by NWFS receive a complete refund less the $10 service fee. Privacy Policy: Northwest Family Services is committed to protecting the privacy of its users and customers, making your internet experience with us safe. The names and email addresses you give us are NOT sold for any type of solicitation. NWFS websites operate secure data networks protected by industry standard firewall and password protected systems. Any sensitive information, such as a customer’s credit card number collected for a commerce transaction, is encrypted prior to transmission.

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