Intake Self Pay
For Non Insured (Cash Pay) patients only
Name
First Name
Last Name
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
Date Picker Icon
E-mail
*
Sex:
Male
Female
Transgender
Gender Non Specific
Status:
Single
Married
Divorced
Widowed
Original Date of Injury: Onset:
*
-
Month
-
Day
Year
Date Picker Icon
Auto Related
Yes
No
Work Related
*
Yes
No
If WC: Adjuster / Case Workers: IF YOU SAID YES TO WORK RELATED, PLEASE MAKE SURE THE FRONT DESK IS AWARE AND WE HAVE AUTHORIZATION TO TREAT YOU
Info
Name
Phone
Email
If workers comp: Have you received Therapy treatment for this condition since the above “Original Date of Injury"?
Yes
No
Other
If so, how many treatment sessions do you remember receiving?
# of treatments received previously
If Workers comp, was accident with present Employer?
Yes
No
Other
If No, who was the employer?
Employer when WC injury happened
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Out of Network coverage
Are you aware of your out of network coverage for therapy?
Do you want us to find out your out of network coverage?
*
Yes
No
Insurance Company Name:
*
Primary Insurance
PPO/ HMO
*
PPO
HMO
If HMO, which network are you on
SCCIPA, Affinity, PAMF, Verity
Upload the picture of front and back of your insurance card and if you have authorization from your insurance company (If needed)
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If you cant upload a picture of your card, then enter the subscriber ID number
Group number
Phone number on the back of the card
Policy Holders Name:
*
First Name
Last Name
Date of Birth (If other than self)
-
Month
-
Day
Year
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Patient relationship to policy holder
Self
Spouse
Dependent
Other
Employer Name
Employer Phone Number
-
Area Code
Phone Number
Employer E-mail
Employment Status
None
FT
PT
Self Employed
Disabled
If Disabled: Total
If Disabled: Temp
Retired
Student
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Emergency Contact Information
Contact Name
*
First Name
Last Name
Contact Phone Number
-
Area Code
Phone Number
Relationship to patient:
Parent
Spouse
Sibling
Other
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
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
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Medical History
Original Date of Injury: Onset:
*
-
Month
-
Day
Year
Date Picker Icon
Have you ever had these symptoms before?
Yes
No
Check which apply to your symptoms:
Work Related Injury
Recurrence of previous injury
Motor Vehicle accident
Injury related to lifting
Cause Unknown
Athletic/Recreational: Injury due to falling
Other
Have you had related surgery:
Yes
No
Do you have, or have you had any of the following ?
No Known Significant Past Medical History To Affect Treatment
Alzheimer's
Cardiovascular Disease
Presence of pacemaker
Cerebral Vascular Accident / Stroke
Current Infection
Diabetes Mellitus Type 1
Diabetes Mellitus Type 2
Hypo Glycaemia
Fibromyalgia
Fibromyalgia
Fracture of Suspected Fracture
High Blood Pressure
Other
History of Cancer
Pregnant
Immunosuppression
Lupus
Muscular Dystrophy
Obesity
Osteoarthritis / Osteoporosis
Parkinsons
Rheumatoid Arthritis
Headaches
Metal Implants
Dizziness/ Fainting
Other
Related UE Injuries/Surgeries
Upper Extremity Surgeries
Recent Fractures
Previous Therapy
Related to the injury
Additional Information
Allergies (to asprin/ heat/ etc.)
Multiple treatment areas
Poor cold tolerance
Psycho-Social
Other allergies
Seizures
Litigation (see below)
Other
Current Medication with Dosages:
Answers
Prescription
Over the counter
Herbals
Vitamin/Mineral/ Dietary Supplements
Other
Not currently taking medication
Attach your medication list
Browse Files
Save your medication file here
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Calculate your BMI
Unexplained Weight Loss:
N/A
No
Yes
Are you a Tobacco User?
N/A
No
Yes
Are you a Smoker?
Yes
No
Past
Tried Cessation
Yes
No
History of Falls:
N/A
No
Yes
If Yes:
Medications are a contributing factor
Medications are not a contributing factor
Home fall hazard
Postural Blood Pressure
Vision
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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.
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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. 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.
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 $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.
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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
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Initial
No-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".
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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.
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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.
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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 and discharge you from therapy
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Initial
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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.
I DO NOT HAVE INSURANCE OR I HAVE NOT MET MY DEDUCTIBLE.I am paying by CASH, CHECK, CREDIT CARD. I understand I will be notified of any and all charges prior to processing Full payment is due at the time of service.
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Initial
NON-CONTRACTED INSURANCE (Policies for which we are an Out of Network Provider under your plan) · Since you are out of network and are not covered at 100%, you will be responsible for $195 for the initial visit and $125 for subsequent visits. This payment is required at the time of each visit. · If we call for coverage and we will give you your out of network benefits, and you will still pay the $95 upfront and then once we receive the payment we will write you there fund check. for the paid amount by your insurance. · We accept cash or check or Visa and MasterCard. There is a $25 charge for all returned checks · You will receive a monthly statement that will show you the status of your account. As a courtesy to our patients, we will verify your out of network coverage 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. Many insurance companies have stipulations that limit the benefit in some way, such as # of visits, supplies, deductibles, co-insurance, co-pays, etc. 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.
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Initial
NON-CONTRACTED INSURANCE NON-CONTRACTED INSURANCE (Policies for which we are an Out of Network Provider under your plan) As a courtesy to our patients, we often accept assignment of benefits from your insurance company after benefits and eligibility has been established, even though we are “Out Of Network”. Under Federal Law, we must collect the patient portion established by your plan. This will be paid at the time services are rendered. Your account balance after the insurance has paid its portion is your responsibility. Balance owing will be billed after the insurance company has finished processing your claim. This can be a long time. Your insurance policy is a contract between you and your insurance company and we are not a party to that contract. If we have accepted assignment we will require you to be pre-approved on our extended payment plan,or you may provide a credit card or debit card with authorization to bill that card for your balance in the event that your insurance company has not paid within 45 days from the date services were rendered. Please be aware that some, and perhaps all, services provided may be considered non-covered services and not considered “reasonable and necessary” under the plan and/or Medicare. We are not advised of this until after billing for services. This option only applies if we are filing for your insurance out of network benefits only.
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Initial
SUPPLIES: Payment for all supplies not covered by insurance is due at the time of service. OTHER SUPPLIES: Electrodes, over the counter splints, exercise equipment's; medicated patches etc are not covered int he cash pay plan. Should you need these supplies we will inform you of the additional cost incurred before providing it to you. Payment will be due at the time of service
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Initial
ORTHOTICS: If your rehab/ physician requires custom fabricated splints, we will furnish that for you, however, under our cash pay agreement you will be responsible for the payment of the splint which is separate from your initial and repeat visits. We offer a 20% discount for all our cash pay customers on custom splints only. If you want us to bill your insurance under the out of network benefits, if you have a prescription but if your insurance does not cover the splint then you will be responsible for the payment of the splint. If billed under the insurance and not covered then we cannot offer you the 20% discount later and you will need to pay the entire cost of the splint. At times even if you have a prescription, the insurance may require a pre-authorization, which may take time and you may have to make a choice of getting the orthotic when needed and discuss it with your insurance provider later or wait for the pre-authorization. Just inform us of your choices, or verify the coverage yourself before you come to therapy.
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Initial
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 (out of network benefits), however, the final payment is your responsibility. Please be aware of this and plan to make payments accordingly.
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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..
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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..
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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.
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Initial
You have Out of Network Benefits and Want Hands-On-Care to file for out of network benefits ?
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Yes (I agree to pay the remainder balance)
No (I prefer to pay for the entire treatment in cash)
A photocopy of this Assignment shall be considered as effective and valid as the original.
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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.
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Initial
I authorize the use of this signature on all insurance submissions
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Initial
I authorize the Hands-On-Care to deposit checks made in my name.
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Initial
I authorize the "Hands-On-Care" to initiate a complaint to the Insurance Commissioner for any reason on my behalf
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Initial
I understand, that I am financially responsible for all charges whether or not paid by insurance.
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Initial
I have read the financial/treatment consent policy and I understand and agree to this policy
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Initial
Signature
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