Intake WC

Intake Workers Compensation

For Workers Comp patients only
Name*

First NameLast Name
Body Part Involved
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*

Area CodePhone Number
Home Phone Number

Area CodePhone Number
Date of Birth *

MonthDayYear
E-mail*
Sex:

MaleFemaleTransgenderGender Non Specific
Status:

SingleMarriedDivorcedWidowed
Original Date of Injury: Onset:*

MonthDayYear
Work Related*

Yes (Auth needed)No (Use PPO form)

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

Emergency Contact Information
Contact Name*

First NameLast Name
Contact Phone Number*

Area CodePhone Number
Relationship to patient:

ParentSpouseSiblingOther
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
WC Physician*
WC Physician Phone Number

Area CodePhone Number
Surgeon (if any)
Surgeons Phone Number

Area CodePhone Number
Attorney Information
Attorney*

YesNo
Attorney Name
Attorney Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

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

YesNoIf 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

	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.

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 (Applies to WC Patients)

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. 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 workers comp insurance is not responsible for these charges, it is your responsibility and not workers comp’s. A lot of time and effort is spent ensuring your appointment slot is held for you. Therefore,if an apt is not kept, and you have not called us in advance, you will be responsible for the fees as listed below.
Attendance Policy: Must check all sections*

24-HOUR ADVANCE NOTICE FEE: If you wish to change or cancel an appointment we require a minimum 24-hour advance notice. Any thing less will result in letting your insurance know of your late cancel. 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.). Advance notice allows someone else (who needs it) time to reserve it in place of you. Please be courteous and responsible. Thank you. Fee: $50 is your responsibilityLATE 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. Being a WC patient and showing up late means you arrive late to work. 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 $50 fee assessed to your account. No show for a WC patient means you failed to show up to work and you could lose your benefits if the insurance so determines it. 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: 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. Since you would'nt take a sick child to your work place, you cannot bring them to a facility with other patient with weak immune systems either. 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
24-Hour Advance Notice Fee: If you wish to change or cancel an appointment we require a minimum 24-hour advance notice. Any thing less will result in letting your insurance know of your late cancel. 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.). Advance notice allows someone else (who needs it) time to reserve it in place of you. Please be courteous and responsible. Thank you. Fee: $50 is your responsibility *
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. Being a WC patient and showing up late means you arrive late to work. 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. No show for a WC patient means you failed to show up to work and you could lose your benefits if the insurance so determines it. 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: 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. Since you would'nt take a sick child to your work place, you cannot bring them to a facility with other patient with weak immune systems either. 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
If you are covered by worker’s compensation insurance and you fail to keep the appointments that are recommended by your therapist and physician, the appropriate parties need to be notified to your absence and will also be noted in your chart. This may include your physician, employer, insurance company, and case manager/rehabilitation nurse. Please understand that failure to actively participate in your rehabilitation program may have a negative effect on your worker’s compensation coverage.

For each NO-SHOW or CANCELLED visit, doctors, employers, and workman’s compensation will be notified. TWO no-shows and/or three cancelled visits will result in discharge from therapy and/ or you may be requiring an appointment with your physician for a new prescription. You WILL BE CHARGED a fee for every NO-SHOW or LAST MINUTE CANCELLATIONS.

We hope you take your therapy and recovery as seriously as we do.

Thank you for your assistance.

I have read and understand the above. I understand that attendance at each therapy session is important to my recovery and will notify my therapist if unable to attend a session so that it may be rescheduled.

Financial Policy

Thankyou 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 toread, check initial and sign prior to treatment.
SUPPLIES: Workers comp pays for most of your supplies, however, it needs to be approved first by the physician(signature) (PR2) then sent to the workers compensation to get approved. At times this may take a few weeks to get approved. We do our best to hasten the process however at times it takes a while to get things approved. We encourage you to contact your workers comp person to approve the supplies ASAP for us to help you in getting better faster. You can also choose to purchase the supplies and get the workers comp to pay for it once the physician signs the prescription. But it is your risk for the taking. WORKER’S COMPENSATION approval is obtained and verified for your convenience before the supply is issued to you. We cannot provide any supplies without payment and without prior authorization. Some Workers Comp insurances require authorization for custom splint. If your physician requested a custom splint on an urgent basis and if the w/c has not approved it we will not be able to furnish the request. *
Initial
Financial Policy (Please check each box)*

SUPPLIES: Workers comp pays for most of your supplies, however, it needs to be approved first by the physician(signature) (PR2) then sent to the workers compensation to get approved. At times this may take a few weeks to get approved. We do our best to hasten the process however at times it takes a while to get things approved. We encourage you to contact your workers comp person to approve the supplies ASAP for us to help you in getting better faster. You can also choose to purchase the supplies and get the workers comp to pay for it once the physician signs the prescription. But it is your risk for the taking. WORKER’S COMPENSATION approval is obtained and verified for your convenience before the supply is issued to you. We cannot provide any supplies without payment and without prior authorization. Some Workers Comp insurances require authorization for custom splint. If your physician requested a custom splint on an urgent basis and if the w/c has not approved it we will not be able to furnish the request.REQUIRING AUTHORIZATIONS: All Workers Compensation require authorization, without authorization, you cannot be seen in therapy and would have to wait to get approval. Every supply given or Splint fabricated has to be approved before it can be provided. Please stay in contact with your WC insurance to get things expedited.
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
REQUIRING AUTHORIZATIONS: All Workers Compensation require authorization, without authorization, you cannot be seen in therapy and would have to wait to get approval. Every supply given or Splint fabricated has to be approved before it can be provided. Please stay in contact with your WC insurance to get things expedited.*
Initial
Assignment of Benefits*

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 Hands-On-Care to deposit checks made in my name by my insurance for the treatment provided.I authorize the "Hands-On-Care" to initiate a complaint to the Insurance Commissioner for any reason on my behalfI have read the financial/treatment consent policy and I understand and agree to this policyI authorize the use of this signature on all insurance submissions
A photocopy of this Assignment shall be considered as effective and valid as the original.*
Initial
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
I authorize the use of this signature on all insurance submissions*
Initial
I authorize the Hands-On-Care to deposit checks made in my name.*
Initial
I authorize the "Hands-On-Care" to initiate a complaint to the Insurance Commissioner for any reason on my behalf*
Initial
I have read the financial/treatment consent policy and I understand and agree to this policy*
Initial
Signature*

Clear
Signature
Should be Empty:

Intake Workers Compensation

Workers Compensation Insurance Information

Emergency Contact Information

Physician Information

Attorney Information

Medical History

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

Permission to use pictures for research / presentations

Patient Attendance Policy (Applies to WC Patients)

Financial Policy