GETTING THERAPY SERVICES STARTED:

Referral process: Midlands Therapy Services accepts referrals from parents, doctors, Babynet, health departments and other state agencies serving children in South Carolina. To self-refer your child for therapy please call us at: 803-359-3195

ONCE WE RECEIVE THE REFERRAL WE WILL NEED:

- Prescription: Whether you self-refer or are referred from your child’s primary physician, we will need a prescription to evaluate and treat for therapy. You can have your physician fax it directly to us at 803-520-8398.

- Proof of insurance: A copy of your primary insurance card and/or your child’s Medicaid card. If your child is covered under your private insurance and also has Medicaid, we ask that you bring both cards to the initial evaluation appointment. Medicaid requires us to bill the primary insurance first before they will pay for services.

- Intake paperwork: Once all of the appropriate information is received we can assign the best therapist(s) to your child. The therapist(s) will call you to set up your child’s first appointment. Before your evaluation please complete the appropriate documents found on the forms page, the information is necessary for the therapists to complete your child’s evaluation. Please be as thorough as possible. (Scroll down to enter patient intake form details or update an existing patient's account)

Patient Intake Form

    Patient Name*

    Date of Birth*

    Gender*

    MaleFemale

    Preferred email address for correspondence:*

    Phone*

    Caregiver Name(s)*

    Relationship*

    Additional Phone#

    Patient Address*

    City*

    State*

    Zip Code*

    Please read and initial each item:

    Consent to Treatment*

    I understand that I have been referred for therapy services and care with Midlands Therapy Services. 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 has been prescribed by my physician and/or recommended by my therapist. By signing this agreement, I consent to have Midlands Therapy Services provide treatment and care as prescribed by my physician and/or recommended by my therapist. I authorize Midlands Therapy Services to use and / or disclose my protected health Information to physicians, payers of health care services and other health care providers to help provide appropriate treatment for my child. I hereby authorize Midlands Therapy Services to furnish my insurance company(s) any information that may be required in order to determine benefits and process claims. I authorize payment of medical benefits to Midlands Therapy Services for services rendered to me. I certify by my signature that I have read the above and agree to these policies.

    Consent to Release and/or Obtain Information*

    • Authorize the contracted therapists and company representatives to disclose and / or obtain specific health /medical and educational information from the records of the above named child
    • Understand that I may request a copy of any information that is disclosed or obtained
    • Agree that a copy of this consent may be treated as an original
    • Understand that if the record contains information relating to HIV infection, AIDS or AIDS-related conditions, alcohol abuse, drug abuse, or genetic testing this disclosure may include that information
    • Understand that this information may be released in any of the following ways: fax, email, direct mail, wireless communication or by telephone
    • Understand that, while services will not be denied because of failure to sign this consent form, inability to collect necessary information may cause denial of eligibility for Therapy Services with Midlands Therapy Services, Inc.
    • Grant consent from the date I sign the consent until discharge of the patient from Midlands Therapy Services,Inc.
    • I authorize Midlands Therapy Services, Inc. to use and/or disclose my protected health information to physicians, payers of health care services and other health care providers to help provide appropriate treatment for my child.

    Contact Information*

    I give consent to leave messages on my voicemail or reminder text messages at preferred number.

    YesNo

    Email Consent for Correspondence

    I acknowledge that Midlands Therapy Services can contact me through email for appointments and other therapy updates. Midlands will make every effort to send emails confidentially through our secure patient portal, using a secure password. Even so, I understand the risks that are associated with using this form of communication, including but not limited to information regarding your child’s treatment may be accessible to other parties on the web. I understand this risk involved with email communications. I may withdraw this consent at any time by written communication with the office manager.

    YesNo
    I understand the practices and policies of Midlands Therapy Services that I have initialed above

    PRIMARY INSURANCE

    Insurance Company

    Member ID Number

    Policyholder's Name

    Group ID

    Relationship to Policyholder:

    Employer

    Insured’s Address: if different from child’s

    Date of Birth: (policy holder’s)

    SECONDARY INSURANCE

    Insurance Company

    Member ID Number

    Policyholder's Name

    Group ID

    Relationship to Policyholder:

    Employer

    Insured’s Address: if different from child’s

    Date of Birth: (policy holder’s)

    Assignment of Benefits:*

    Midlands Therapy Services will make every effort to work with our clients regarding services whether payment may be through insurance, private pay, co-payment or other agreements.

    I certify that the information given by me in applying for payment is correct. I hereby authorize payment by my insurance carrier of the benefits, otherwise payable to me, to be made directly to Midlands Therapy Services for their services.
    I authorize Midlands Therapy Services to release all insurance companies and/or compensation carriers only such as diagnostic, therapeutic, and financial information as may be necessary to determine benefits entitled and to process payment claims for health services that will be provided.
    I understand and agree that I am financially responsible for all co-pays, coinsurance and amounts not covered by my healthcare provider. This charge is expected at time of services. Exception as required by Babynet/Medicaid
    I understand that I am obligated to provide ALL insurance information and must notify Midlands Therapy Services immediately should this information change. I understand that failure to comply with this policy will result in patient responsibility for any unpaid balances.

    Midlands Therapy Services Attendance/Cancellation Policy*

    1. I understand that if my child becomes ill I should cancel therapy until my child has remained fever-free (without pain relievers) and/or symptom free for at least 24 hours. Symptoms include: diarrhea, throwing up, rashes, strep throat (must be on antibiotics for at least 24 hours), and severe cold / flu symptoms as determined.
    2. I understand that if I must cancel a therapy session, I should call my therapist at least 24 hours before the session. The therapist will provide me with her contact number.
    3. I understand that Midlands Therapy Services, Inc. may discontinue services when 2 sessions are missed without prior notification. (No Shows)
    4. I understand that excessive cancellations will also provide MTS inc. reason for discontinuing services. This will be determined at the discretion of the owner of the company.
    5. I understand that Midlands Therapy Services, Inc. will try to reschedule any therapy sessions that are canceled by either the patient or the therapist.

    I give Midlands Therapy permission to disclose my child's health information to:

    Name of Person (i.e family member)

    Relationship to Patient

    Additional member (If any):

    Name of Person (i.e family member)

    Relationship to Patient

    Release of Medical Records

    Many insurances require IEPs and IFSPs for authorizations and payment for therapy services. Therefore, failure to allow Midlands to obtain these records may prevent your child from receiving services at Midlands Therapy Services. I authorize Midlands Therapy Services to obtain, use, release and/ or disclose my protected health information to physicians, payers of healthcare services, and other healthcare providers to help provide appropriate treatment for my child.

    Does your child receive school therapy services or early intervention services through an IEP or IFSP?*

    YesNo

    If yes, do you give Midlands permission to obtain the IEP or IFSP?*

    YesNoN/A

    Current School/Contact Person:

    My child is not receiving special education or therapy services through an IEP or IFSP at this time

    To be released to:

    Midlands Therapy Services, Inc, P.O. Box 708 Lexington, SC 29071-0708

    Parent/Guardian Name*

    Name of Child*

    Date*

    I CONSENT THE PERMISSION TO DISCLOSE AND RELEASE OF MEDICAL RECORDS AS PROOF FOR INSURANCE.

    Signature Here*