Getting Therapy Services Started:

Referral process: Southland Therapy accepts referrals from parents, doctors, Babynet, health departments and other state agencies serving children in Georgia and South Carolina. To self-refer your child for therapy please call us at: Georgia: 912.335.1650 or South Carolina: 803.398.1881 or 843.501.1816

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 for therapy. *You can obtain this yourself or we can request it from your physician for you.

- 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/ patient screening forms: 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 Southland 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 Southland Therapy Services provide treatment and care as prescribed by my physician and/or recommended by my therapist. I authorize Southland 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 Southland 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 Southland 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 Southland Therapy Services, Inc.

    • Grant consent from the date I sign the consent until discharge of the patient from Southland Therapy Services,Inc.

    • I authorize Southland 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

    Consent to release photo/ video of your child:

    Therapists sometimes use photos/ videos to track the progress of the child’s treatment program. I give permission for therapists to take a photo/ video of my child for treatment purposes only. I understand additional approval would be requested for permission to use such photo or video for promotional purposes (website, brochures, newsletter, other advertisement).

    YesNo

    Email Consent for Billing

    I acknowledge that Southland can contact me through email for appointments, financial statements and other office updates. Southland 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 would like to receive my billing and financial statements through email.*

    YesNo

    I understand the practices and policies of Southland 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:*

    Southland Therapy Services will make every effort to work with our clients regarding obligations for 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 Southland Therapy Services for their services.
    I authorize Southland 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.
    I understand that I am obligated to provide ALL insurance information and must notify Southland immediately should this information change. I understand that failure to comply with this policy will result in patient responsibility for any unpaid balances.

    Southland Therapy Services Attendance/Cancellation Policy*

    We are committed to providing quality consistent services to our clients. Therapy will be most beneficial to your child with consistent attendance. It is also important that you arrive on time so that your child can benefit from a full session. We appreciate your cooperation with our attendance/ Cancellation policy.

    1. Please arrive on time for your therapy session. Patients arriving more than 10 minutes past the scheduled appointment time will be considered a no show and the appointment could be cancelled. Routine tardiness may result in billing that time directly to you. In order for us to plan appropriately for staff, we require that parents call to cancel the appointment for illness or an unavoidable conflict as soon as possible. We reserve the right to charge a fee of $25.00 for missed unexcused absences and for arriving 10 or more minutes late. Full payment of any assessed cancellation fees must be paid in full before your child may return to therapy. Any unpaid no show or late cancellation fees over 90 days may result in turning the account over to a third-party collection agency.

    2. 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.

    3. Please make every attempt to reschedule non illness related missed appointments.

    4. 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 or you may call the office at 912.335.1650 to cancel.

    5. I understand that Southland Therapy Services, Inc.(STS) may discontinue services when 2 sessions are missed without prior notification. (No Shows)

    6. I understand that excessive cancellations will also provide STS inc. reason for discontinuing services. This will be determined at the discretion of the owner of the company.

    7. I understand that STS will try to reschedule any therapy sessions that are cancelled by either the patient or the therapist.

    8. It is the parent/ caregivers responsibility to remain current with well visits to the primary care physician(PCP). Should your Rx for therapy expire, STS will contact your PCP for an updated Rx. HOWEVER if the physician will not write a new therapy prescription without the patient attending a well visit appointment, STS is REQUIRED to place your child on HOLD and discontinue services until an updated Rx is obtained.

    9. I understand that by coming to the office (opting for in person therapy), I am assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service. I understand that Southland is committed to keeping me, you [our staff] and all of our families safe from the spread of this virus or any other contagious disease. If you show up for an appointment and we [office staff] believe that you have a fever or other symptoms, or believe you have been exposed, we will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate. Southland Therapy will continue to follow the current CDC recommended guidelines in place for disease control including but not limited to routine cleaning, hand washing, face coverings, and social distancing and we expect the same from our patient and families. I will cancel any appointments if my child or any member of my family is running a fever on the day of the scheduled appointment. I will not be charged a cancellation fee.

    I give Southland 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 Southland to obtain these records may prevent your child from receiving services at Southland Therapy Services. I authorize Southland Pediatric Therapy 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.

    Child's Pediatrician's Name*

    Email address for IEP and\or Hearing Screening*

    Upload Copy of IEP Screening

    How did you hear about Southland?

    Consent to release photo/ video of your child

    Yes for treatment purposesYes for treatment and promotional purposesNo

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

    YesNo

    If yes, do you give Southland 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:

    Southland Pediatric Therapy, 1000 Eisenhower Dr. Suite H Savannah, Ga 31406

    Southland Therapy Services, P.O. Box 30606 Savannah, Ga 31410

    Parent/Guardian Name*

    Name of Child*

    Date*

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

    Signature Here*

    Invoices and Statements

    Email Address*

    Phone Number