Intake Medicare

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Intake Medicare

For subscribers of Medicare as Primary Insurance only. If Medicare is Secondary Insurance, Use PPO/ HMO form. All items with * required
Name*

First NameLast Name
Body Part Involved*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*
For appointment reminders
Cell Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Date of Birth *

MonthDayYear
Sex:

MaleFemaleTransgenderGender Non Specific
Status:

SingleMarriedDivorcedWidowed
Original Date of Injury: Onset:*

MonthDayYear
Auto Related

YesNo
Work Related*

YesNo
Is your claim still open for the same injury

YesNo

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

YesNoOther
If so, how many treatment sessions do you remember receiving?
# of treatments received previously
If Workers comp, was accident with present Employer?

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

	Info
Name
Phone
Email

	Answers
Prescription
Over the counter
Herbals
Vitamin/Mineral/ Dietary Supplements
Other
Not currently taking medication

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.

Picture Release

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*

YesI do not grant Hands-On-Care permission to use my videos and pictures for futuretalks

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 (All sections need to be checked off)*

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 $95 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 $95 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 applyNO-SHOWS are BAD: If you fail to show for an appointment without notice all future appointments will be removed and a $95 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 youCHILDREN 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 othersCourtesy 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 and discharge you from therapyTREATMENT 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.*
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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

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.
CONTRACTED INSURANCE: (Policies for which we are an In Network Provider under your plan) All items must be checked*

Unless 100%coverage has been verified with no copay, no co-insurance, and no deductible, you are responsible for the copay/co-insurance per visit and/or deductible not covered by your insurance company. This payment is required at the time of each visit. If you are contracted with Medicare, then Medicare will subtract your deductible and co-insurance from the $3000 cap and pay 80%. The 20% co-insurance, will be paid by you or a supplemental insurance that you may have. These limits are based off the Medicare fee schedule allowed amount after your $185 deductible has been met. The cap will be based on services paid by Medicare at the allowable rate, not the provider's charges. The secondary will only cover the 20% of what Medicare covers, if Medicare doesn’t cover a service, your secondary will NOT cover it. If your secondary is out of network, you may be responsible for the 20% at the time of service. · We accept cash or check or Visa /MasterCard bankcards. There is a $25 charge for all returned checks · You will receive a monthly statement that will show you the status of your accountAs a courtesy to our patients, we will verify and file your claim with your insurance company; however, we cannot guarantee payment. We strongly suggest that you read your policy manual as it pertains to occupational therapy coverage Part B, in an Out Patient Office Setting. Medicare has stipulations that limit the benefit by a cap amount mentioned above, along with supplies, deductibles and 20% coinsurance. These stipulations should be noted in your policy manual. Final determination of benefits and your financial responsibility will be determined by your Insurance Carriers Payment to Hands-On-Care. All Deductibles are due at the time of treatment. Should the patient portion of your insurance policy require you to pay a certain percentage, we will collect that amount at the time of your visit. Occasionally, charges are reduced due to contracted fee schedules, resulting in your portion being lower than what you actually paid. When all visits have been processed and paid by the insurance, we will at that time refund over payments due to you,or bill you for any underpayment. We cannot do this in advance, as the insurance company can make many changes during processing. 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. In cases where we are not in network, please refer to the paragraph belowSUPPLIES: Medicare does not cover supplies. You are responsible for payment for all supplies used in your treatment at the time of each visit.ITEMS NOT COVERED BY YOUR INSURANCE ARE YOUR RESPONSIBILITY. We have an agreement with you, not your insurance company, for receipt of payment. We will file your insurance for payment for your convenience, however, the final payment if your responsibility. Please be aware of this and plan to make payments accordingly.USUAL AND CUSTOMARY RATES: Our practice is committed to providing the best treatment to our patients. We charge no more than usual and customary for our area, and frequently less. You are responsible for payment regardless of what your insurance company calls“usual and customary” rates.RESPONSIBILITY: I understand that I am financially responsible for payment of all charges for services rendered to me, including the balance remaining after payment of insurance benefits. I authorize payment of medical benefits to Hands-On-care. I understand if I have an unpaid balance to Hands-On-care and do not make satisfactory payment arrangements, my account may be placed with an external collection agency, including all costs and expenses incurred collecting my account, and possibly including reasonable attorneys's fees if so incurred during collection efforts. In order for Hands-On-Care or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that Hands-On-Care and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable. I authorize release of any medical information or records to the insurance company for the purpose of payment. I authorize release of my medical records to my doctor for continuity of care.
CONTRACTED INSURANCE: (Policies for which we are an In Network Provider under your plan) · Unless 100%coverage has been verified with no copay, no co-insurance, and no deductible,you are responsible for the copay/co-insurance per visit and/or deductible not covered by your insurance company. This payment is required at the time of each visit. · If you are contracted with Medicare, then Medicare will subtract your deductible and co-insurance from the $3000 cap and pay 80%. The 20% co-insurance, will be paid by you or a supplemental insurance that you may have. These limits are based off the Medicare fee schedule allowed amount after your $185 deductible has been met. The cap will be based on services paid by Medicare at the allowable rate, not the provider's charges. The secondary will only cover the 20% of what Medicare covers, if Medicare doesn’t cover a service, your secondary will NOT cover it. If your secondary is out of network, you may be responsible for the 20% at the time of service. · We accept cash or check or Visa /MasterCard bankcards. There is a $25 charge for all returned checks · You will receive a monthly statement that will show you the status of your account.*
Initial
· As a courtesy to our patients, we will verify and file your claim with your insurance company; however, we cannot guarantee payment. We strongly suggest that you read your policy manual as it pertains to occupational therapy coverage Part B, in an Out Patient Office Setting. Medicare has stipulations that limit the benefit by a cap amount mentioned above, along with supplies, deductibles and 20% coinsurance. These stipulations should be noted in your policy manual. Final determination of benefits and your financial responsibility will be determined by your Insurance Carriers Payment to Hands-On-Care. All Deductibles are due at the time of treatment. Should the patient portion of your insurance policy require you to pay a certain percentage, we will collect that amount at the time of your visit. Occasionally, charges are reduced due to contracted fee schedules, resulting in your portion being lower than what you actually paid. When all visits have been processed and paid by the insurance, we will at that time refund over payments due to you,or bill you for any underpayment. We cannot do this in advance, as the insurance company can make many changes during processing. 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. In cases where we are not in network, please refer to the paragraph below *
Initial
SUPPLIES: Medicare does not cover supplies. You are responsible for payment for all supplies used in your treatment at the time of each visit.ITEMS NOT COVERED BY YOUR INSURANCE ARE YOUR RESPONSIBILITY. We have an agreement with you, not your insurance company, for receipt of payment. We will file your insurance for payment for your convenience, however, the final payment if your responsibility. Please be aware of this and plan to make payments accordingly. *
Initial
USUAL AND CUSTOMARY RATES: Our practice is committed to providing the best treatment to our patients. We charge no more than usual and customary for our area, and frequently less. You are responsible for payment regardless of what your insurance company calls“usual and customary” rates..*
Initial
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..*
Initial
RESPONSIBILITY: I understand that I am financially responsible for payment of all charges for services rendered to me, including the balance remaining after payment of insurance benefits. I authorize payment of medical benefits to Hands-On-care. I understand if I have an unpaid balance to Hands-On-care and do not make satisfactory payment arrangements, my account may be placed with an external collection agency, including all costs and expenses incurred collecting my account, and possibly including reasonable attorneys's fees if so incurred during collection efforts. In order for Hands-On-Care or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that Hands-On-Care and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable. I authorize release of any medical information or records to the insurance company for the purpose of payment. I authorize release of my medical records to my doctor for continuity of care.*
Initial
Assignment of Benefits (All items must be checked)*

A photocopy of this Assignment shall be considered as effective and valid as the original. I authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or attorney involved in this case for the purpose of processing claims and securing payment of benefits.I authorize the use of this signature on all insurance submissions, I authorize the Hands-On-Care to deposit checks made by the insurance company for the therapy visits in my name.I authorize the "Hands-On-Care" to initiate a complaint to the Insurance Commissioner for any reason on my behalfI understand, that I am financially responsible for all charges whether or not paid by insurance
A photocopy of this Assignment shall be considered as effective and valid as the original. I authorize the release of any medical or other information pertinent to my case to any insurance company, adjuster, or attorney involved in this case for the purpose of processing claims and securing payment of benefits.*
Initial
Initial
I authorize the use of this signature on all insurance submissions, I authorize the Hands-On-Care to deposit checks made in my name. I authorize the "Hands-On-Care" to initiate a complaint to the Insurance Commissioner for any reason on my behalf*
Initial
Initial
I authorize the "Hands-On-Care" to initiate a complaint to the Insurance Commissioner for any reason on my behalf*
Initial
I understand, that I am financially responsible for all charges whether or not paid by insurance. *
Initial
I have read the financial/treatment consent policy and I understand and agree to this policy*
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Intake Medicare

Medicare is your Primary Insurance?

Secondary Insurance Information

Emergency Contact Information

Physician Information

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Attorney Information

Medical History

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Picture Release

Patient Attendance Policy for your Insurance

Financial Policy

Medicare Secondary Payer (MSP) Form