New Patient Forms Required for Initial Visit (download and print)
Health by Hand Wellness Center offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive for your initial visit.
Our New Patient Health History Form lets us know your medical history and current condition. This form is required for your initial consultation with Dr. Kathi.
If you do not already have AdobeReader installed on your computer, you can find a free download online.
Download the necessary form(s) noted below as “required for initial visit”, print it out and fill in the required information. Bring the completed forms with you to your appointment. If you have current x-rays, please bring those with you along with the New Patient form.
If you miss an appointment, without a minimum of 24 hours' notice, you will be charged for the time that you were scheduled ($140/hour, $86/half hour). This amount must be paid before you will be treated again. If you arrive more than 10 minutes late without calling you will need to reschedule and you will be charged, or you may wait and be worked in as time permits. The nature of our practice is to spend individual time with our patients and if you cancel or are late we cannot fill your time slot without 24 hours' notice.
Thank you for your cooperation.
Find out if Dr. Kathi’s “Beyond Chiropractic” healthcare is for you!
Consultation with Dr. Kathi
Only $200 for new patients.
NOTICES OF PRIVACY PRACTICES (Effective April, 2003)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, ALSO HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Understanding your health record
A record is made each time you are treated at our Clinic. Your injuries, evaluation, test results, diagnosis, treatment, and a plan of care are recorded. This information is most often referred to as your “health or medical record”, and serves as a basis for planning your care and treatment. It also serves as a means of communication among any and all other health professionals who may contribute to your care. Understanding what information is retained in your record and how that information may be used will help you to ensure it’s accuracy, and enable you to relate to who, what, when, where and why others may be allowed access to you health information. This effort is being made to assist you in making informed decisions before authorizing the disclosure of your medical information to others.
Understanding your health information rights
You have the right to request restrictions on certain uses and disclosures of your information, and to request amendments be made to your health record. This Clinic is not required to accept your requests and you cannot request restrictions on uses or disclosures otherwise required by law. Your rights include being able to review or obtain a paper copy of your health information, and are given an account of all disclosures. You may also request communication of your health information be made by alternative means or to alternative locations in a confidential manner. This Clinic is required by law to accommodate reasonable request to receive communications of health information by alternative means or to alternative locations if you clearly state that disclosures of all or part of the information that could endanger you. This Clinic may require you to submit a written request for any of the documents or actions that you have a right to under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
This Clinic is required by law to maintain the privacy of your health information and to provide you with notice of our legal commitment and privacy practices with the respect to the information we collect and maintain about you. This Clinic is required to abide by the terms of this notice, as currently in effect, and to notify you if we are unable to grant your requested restrictions or locations. This Clinic reserves the right to change its practices and effect the new provisions with respect to all health information that it maintains (including such information that this Clinic had prior implementation of the new provisions).
Use and disclosure of your Health Information without your authorization
This Clinic may use and disclose your health information in order to provide ‘Treatment”, obtain “Payment” and perform our “Health Care Operations”, as well as other specific reasons detailed below:
Treatment — information obtained by your provider in this Clinic will be recorded in your medical record and used to determine the course of treatment. This consists of your provider recording his/her own expectations and those of others involved in providing your care. The sharing of your health information may progress to others involved in your care, such as physicians.
Payment — Your health care information will be used in order to receive payment for services rendered by this Clinic. A bill may be sent to either you or a third party payer with accompanying documentation that identifies you, your diagnosis, procedures performed and supplies used.
Health Care Operations — Dr. Kathi will use your health information to assess the care you received and the outcome of your cases compared to others like it. Your information may be reviewed for risk management or quality improvement purposes in our efforts to continually improve the quality and effectiveness of the care and services we provide.
Business Associates — Some or all of your health information may be subject to disclosure through contracts for services to assist this Clinic in proving health care. To protect your health information, we require these Business Associates to follow the same standards held by this Clinic through the terms detailed in a written agreement.
Notification — Your health record may be used to notify or assist family members, personal representatives, or other persons responsible for your care to enhance your well-being or your whereabouts.
Communications with Family — Using best judgement, a family member, or close personal friend, identified by you, may be given health information relevant to your care and/or recovery.
Worker’s Compensation — This Clinic will release information to the extent authorized by law in matters of worker’s compensation.
Public Health — This clinic is required by law to disclose your health information to public health and/or legal authorities charged with tracking reports of birth and morbidity. This Clinic is further required by law to report communicable diseases, injury, or disability.
Law Enforcement — This Clinic may disclose your health information to the police or other law enforcement officials as required or permitted under state law or in response to a valid court, grand jury, or administrative subpoena.
Health Oversight Activities — This Clinic may disclose your health information to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with rules of government health programs, such as Medicare.
Victims of Abuse, Neglect, or Domestic Violence — If this Clinic reasonably believes that you are a victim of abuse, neglect, or domestic violence, it may disclose your health information to the appropriate governmental authority, authorized by law to receive reports such as abuse, neglect, or domestic violence.
Judicial and Administrative Proceedings — This Clinic may disclose your health information in the course of a judicial proceeding in response to a legal order or other lawful purpose.
As required by Law — This clinic may use and disclose your health information when required to do so by any other law not already referred to in the proceeding categories.
Use or disclosure of your health information with written authorization
Any other use or disclosure of your health information, other than those listed above, will only be made with your written authorization. You may revoke your authorization at any time, except to the extent this Clinic used or disclosed your health information in reliance of your authorization.
To receive additional information or report a problem
For further explanation of this notice or any complaints about your Privacy rights, or how Health by Hands Wellness Center has handled your health information please contact us at 817-930-0600. If nobody is available to answer your concerns please feel free to make an appointment for a conference in person or by phone within 2 working days.
If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:
DHHS, Office of Civil Rights 200 Independence Avenue. S.W. Room 509F HHH Building Washington. DC 20201
I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.