Consent Form and Student Self-Pay Refund Policy

Effective upon submission of this Consent for Disclosure of Personally Identifiable Information (“Consent”), I hereby authorize Clinical Placement Consortium #1, North Puget Sound Clinical Placement Consortium, and Inland Northwest Clinical Placements Consortia (collectively referred to as “CPNW”) to disclose and provide my personally identifiable information as provided in this Consent.

The personally identifiable information subject to this Consent (“PII”) includes any and all personally identifiable information I have provided to CPNW. My personally identifiable information may include my contact, identification, and demographic information; my educational affiliations, including but not limited to the educational institutions’ verification of such affiliations; copies of documentation relating to my immunizations; history of infectious diseases; titer levels; background checks; personal identity, including but not limited to social security number; nursing skills check-off lists; results of health training modules on such topics as compliance requirements, patient confidentiality, HIV/AIDS, and universal infectious disease precautions; and other records and documentation which may include other personally identifiable, sensitive information that I have provided to CPNW.

I authorize CPNW to disclose this personally identifiable information upon request to:

  • The healthcare educational institution with which I am associated for purposes of the services that CPNW is providing to me (“School”), for purposes of verifying my PII; and
  • Any healthcare organization which has an agreement with CPNW authorizing them to obtain such information for clinical placement purposes (“Affiliated Organizations”), for clinical placement purposes.

I understand I have the right to revoke this authorization by electronic request to CPNW at cpnw@cpnw.org. I understand the revocation will not apply to information that has already been released in response to this authorization.

I further understand that once the PII I have authorized to be disclosed reaches the recipient, that person or organization may use or re-disclose it, and that CPNW has no control over or responsibility for such use or disclosure.

By completing the following information and submitting this form to CPNW, I acknowledge that I have been informed of and consent to the terms and conditions of this Consent, and that CPNW will rely upon this Consent in disclosing my PII.

REFUND POLICY FOR STUDENT SELF PAY AND PROGRAM PAY

The following Refund Policy applies only to students who pay via Paypal at time of registration to CPNW. The Refund Policy does not apply to students whose CPNW fee is covered by their program.

Statement

CPNW understands circumstances arise which may interfere in the student’s preparation, decision to pursue or actual delivery of a clinical experience. If certain qualifications are met, CPNW can refund and close a student’s account and/or provide an adjustment to the programs invoice.

  1. CPNW provides on-boarding services to students prior to their clinical learning experience via a web-based application.
  2. Payment for services is collected at the time of registration for a student self-pay account.
  3. Services are rendered after student establishes a registered account with CPNW.

Conditions

A student or program is qualified to receive a refund or invoice adjustment of the CPNW account registration fee if the student has not received any CPNW Services. This includes but is not limited to eLearning Modules, OIG/GSA checks, Clinical Passport completion, or requested placement approval to a healthcare facility. The student self-pay refund must be requested within 30 days from payment. A program pay invoice adjustment must be requested prior to payment.

Procedure

  1. The student and/or education program will contact support@cpnw.org to request a refund or invoice adjustment, stating reason for refund.
  2. Request will be submitted to the Executive Director for review.
  3. CPNW IT Support will provide the following necessary program and/or account information to the Executive Director for review. For example, Student Self Pay will require the following:
    • Username
    • Transaction amount
    • Transaction date
    • PayPal transaction ID
    • CPNW transaction ID
  4. If refund conditions are satisfied, Executive Director will forward all information to the CPNW Treasurer to issue the refund or invoice adjustment.
  5. Self-pay refunds will be made to students within 7 business days upon Executive Director approval.
  6. Invoice Adjustments will be made to the program within 14 business days upon Executive Director approval.
  7. All student self-pay refund transactions will be assessed a 15% processing fee.
  8. Student account will be closed and archived.