• Intake Workers Compensation

    For Workers Comp patients only
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  • Workers Compensation Insurance Information

    This paperwork is not for Auto or Litigation. WC patients cannot be seen without an auth. A prescription from a doctor is not an authorization.
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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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  • 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 (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.
  • 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.
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