• Intake PPO/ HMO

    For subscribers of PPO or HMO policies only
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  • Primary Insurance Information

    List the name of Insurance and relationship to policy holder with DOB and attach a picture of the front and back of the card. If card is attached you don't have to fill the rest of the info out.
  • In the event that your insurance coverage changes to a plan under which we are not a provider, please inform us and provide us with your new insurance info. If you do not inform us of the change in coverage immediately and the insurance denies payment due to time limits on the processing, you will be responsible for the payment and will be charged the cash pay amount for the visits not covered.edit this text...

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  • Secondary Insurance Information

    (Backup if Auto, Workers Comp. Or Litigation)
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  • Emergency Contact Information

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  • 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
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  • Attorney Information

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  • Medical History

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  • Information needed by your Insurance Company

  • 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
  • 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.
  • Financial Policy

    Thank you for choosing Hands-On-Care as your health care provider. We are committed to your treatment being successful. The following is a statement of our financial policy which we require you to read, check initial and sign prior to treatment.
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