Intake PPO/ HMO

Intake PPO/ HMO

For subscribers of PPO or HMO policies only
Name *

First Last
Body Part Involved
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number *

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Date of Birth *

Month Day Year
E-mail *
Sex:

Male Female Transgender Gender Non Specific
Status:

Single Married Divorced Widowed
Original Date of Injury: Onset: *

Month Day Year
Auto Related

Yes No
Work Related *

Yes No

If workers comp: Have you received Therapy treatment for this condition since the above “Original Date of Injury"?

Yes No
If so, how many treatment sessions do you remember receiving?
# of treatments received previously
If Workers comp, was accident with present Employer?

Yes No
If No, who was the employer?
Employer when WC injury happened

Emergency Contact Information
Contact Name *

First Name Last Name
Contact Phone Number

Area Code Phone Number
Relationship to patient:

Parent Spouse Sibling
Physician Information

The doctor who sent you here, If you change physician please inform us so we can send the report to the correct doctor
Physician *
Physician Phone Number

Area Code Phone Number
Physician E-mail
Physician Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Attorney Information
Attorney

Yes No
Attorney Name
Attorney Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I hereby consent to release Medical Records to this Attorney

Yes No If i change attorneys i will inform Hands-On-Care in writing, if not this serves as a consent to release information to the attorney mentioned above

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in my treatment directly and indirectly.Obtain payment from third party payers.Conduct normal healthcare operations such as quality assessments and physician certifications. I acknowledge that I have knowledge of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information available online at http://www.hocinc.us I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that you are not required to agree to my request restrictions, but if you do agree then you are bound to abide by such restrictions.

Permission to use pictures for research / presentations

The picture here indicates your hand/ or upper extremity. We conceal the identity to the best of our ability
I hereby grant permission for picture taken and / or my video recorded,and grants Hands-On-Care the permission to use my picture/ video without restriction for educating public. It can be printed, projected for this meeting or future meetings. I also acknowledge that Hands-On-Care may not use the picture / video at this time but may so use it at a later date at its own discretion.I expressly release Hands-On-Care or representative or any institution transmitting or exhibiting my picture or video from any claims arising from such use or distribution.I agree to be fully responsible for my own participation and hold Hands-On-Care /representatives harmless from any liability, loss or expense arising from the use of my picture or video. Hands-On-Care reserves the right to discontinue use to photos without any notice

Yes I do not grant Hands-On-Care permission to use my videos and pictures for future talks

Patient Attendance Policy for your Insurance

It is our policy at Hands-On-Care to give prompt, courteous service to all our patients. In order for us to deliver service in this manner, we schedule individual appointments. We try to schedule these appointments so that they are convenient to you. It is important for you to arrange your schedule so that you can be on time for these appointments.If you are unable to attend or you will be late for your appointment, please notify the center in advance. Calling after hours WILL NOT be acceptable. If necessary, at that time you can reschedule the missed appointment. Failure to attend your session may hinder your recovery process. By notifying the center in advance if you cannot keep your appointment, or if you will be late, we are able to rearrange our schedule to accommodate you as well as other patients. Your insurance is not responsible for these charges, it is your responsibility. A lot of time and effort is spent ensuring your appointment slot is held for you. Therefore, if an appointment is not kept, and you have not called us in advance, you will be responsible for the fees as listed below. Please initial as an acknowledgement that you have read it and agree to it.
Attendance Policy *

24- HOUR ADVANCED NOTICE FEE: If you wish to change or cancel an appointment we require a minimum 24-hour advance notice. Anything less will result in a $50 fee charged to your account. It costs us money to make appointments available to you whether you attend or not we still accrue the expenses (for staff wages, rent, etc.). We don't charge you the actual cost for that appointment but rather a mere $50 fee. We do NOT make money with this charge;it's only to act as a deterrent from making last minute changes. Advance notice allows someone else(who needs it) time to reserve it in place of you. Please be courteous and responsible. Thank you. LATE POLICY "10-minutes": Being late by more than 10 minutes will require you to either reschedule or wait for the next available opening. There are no guarantees since openings due to cancellations are unpredictable. We do not allow appointment overlap because this undeservedly compromises the care of another patient. If you arrive later than 10 mins past your scheduled appointment a $25 fee will apply. If you call at the last minute to change your appointment to a later time at the last minute that also is considered as a late policy and will be assessed $25. And if you cancel the appointment then it will be subjected to a last minute cancellation fee of $50 NO SHOWS are bad: If you fail to show for an appointment without notice all future appointments will be removed and a $50 fee assessed to your account. You may re-schedule appointments again on a"first come, first serve basis". CELL PHONES must be shut OFF or silent: We realize emergencies may arise and therefore allow you to carry your cell phone during your session, however, please be courteous and set to silent mode or turnoff. Thank you. CHILDREN requiring supervision are NOT allowed to attend sessions with you: Unless your facility offers child care services, you may not bring children who require supervision with you to your appointment. If your child does not require supervision and is capable of waiting for you quietly in the WAITING ROOM then you may bring them. If any disturbance is caused to other patients or staff members you may be asked to terminate your session early and attend to your child. Also please DO NOT bring a SICK child to our clinic, just because they cannot be kept at a day care. We do not want the spread of infection at our facility either just like day care. Please be courteous to others Courtesy Reminder: As a courtesy to you, we provide you with 1 phone calls and 1 email to remind you to schedule your appointment if you haven't been coming, after that we inform your physician or workers comp adjuster and discharge you from therapy TREATMENT CONSENT: I understand that I have been referred for rehabilitative treatment and care to a Hands-On-Care Outpatient Rehabilitation Center. Hands-On-Care has described for me my individual treatment plan. I understand that I have the right to ask and have any questions answered prior to receiving any treatment, including any risks or alternatives to the treatment plan that was prescribed by my physician and/or recommended by my therapist. By signing this agreement, I consent to have Hands-On-Care Outpatient Rehabilitation provide treatment and care as prescribed by my physician and/or recommended by my therapist..
24-Hour Advance Notice Fee: If you wish to change or cancel an appointment we require a minimum 24-hour advance notice. Anything less will result in a $50 fee charged to your account. It costs us money to make appointments available to you whether you attend or not we still accrue the expenses (for staff wages, rent, etc.). We don't charge you the actual cost for that appointment but rather a mere $50 fee. We do NOT make money with this charge;it's only to act as a deterrent from making last minute changes. Advance notice allows someone else(who needs it) time to reserve it in place of you. Please be courteous and responsible. Thank you. *
Initial
Late Policy "10-minutes": Being late by more than 10 minutes will require you to either reschedule or wait for the next available opening. There are no guarantees since openings due to cancellations are unpredictable. We do not allow appointment overlap because this undeservedly compromises the care of another patient. If you arrive later than 10 mins past your scheduled appointment a $25 fee will apply *
Initial
No-shows are bad: If you fail to show for an appointment without notice all future appointments will be removed and a $50 fee assessed to your account. You may re-schedule appointments again on a"first come, first serve basis". *
Initial
Cell phones must be shut OFF or silent: We realize emergencies may arise and therefore allow you to carry your cell phone during your session, however, please be courteous and set to silent mode or turnoff. Thank you. *
Initial
Children requiring supervision are NOT allowed to attend sessions with you: Unless your facility offers child care services, you may not bring children who require supervision with you to your appointment. If your child does not require supervision and is capable of waiting for you quietly in the waiting room then you may bring them. If any disturbance is caused to other patients or staff members you may be asked to terminate your session early and attend to your child. Also please do not bring a sick child to our clinic, just because they cannot be kept at a day care. We do not want the spread of infection at our facility either just like day care. Please be courteous to others. *
Initial
Courtesy Reminder: As a courtesy to you, we provide you with 1 phone calls and 1 email to remind you to schedule your appointment if you haven't been coming, after that we inform your physician or workers comp adjuster and discharge you from therapy *
Initial

Intake PPO/ HMO

Primary Insurance Information

Secondary Insurance Information

Emergency Contact Information

Physician Information

Attorney Information

Medical History

Information needed by your Insurance Company

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Permission to use pictures for research / presentations

Patient Attendance Policy for your Insurance

Financial Policy