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.
Please be as thorough as possible. Scroll down to enter patient intake form details or update an existing patient's. Please leave this field empty. Male Female. Yes No. 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 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. I understand that I can request a copy of this policy at any time. I give Southland Therapy permission to disclose my child's health information to: Name of Person i.
Additional member (if any):
Intake Form. 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: Once we receive the referral we will need:. Patient Intake Form. Additional Phone. I hereby authorize Southland Therapy Services to furnish my insurance company s any information that may be required appointments 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 ature that I have read the above and agree southland these policies. Grant consent from the date I the consent until Carolina of the patient from Southland Therapy Services,Inc. I authorize Southland Therapy Services, Inc. I understand additional approval would be requested for permission to use such photo or video for promotional purposes website, brochures, newsletter, other advertisement. Consent for Billing I acknowledge that Southland can contact me through for appointments, financial statements and other office updates.
Southland will make every effort to send s confidentially through our secure patient portal, using a secure password.
I understand this risk involved with communications. I may withdraw this consent at any time by written communication with the office manager. I would like to receive my billing and financial statements through .
I understand the practices and policies of Southland Therapy Services that I have initialed above. Member ID .
Policyholder's Name. Group ID. Relationship to Policyholder:. 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. 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.
Please read and initial each item:
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 over to a third-party collection agency. Please make every attempt to reschedule non illness related missed appointments. 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 or you may call the office at I understand that Southland Therapy Services, Inc. STS may discontinue services when 2 sessions are missed without prior notification. This will be determined at the discretion of the owner of the company. I understand that STS will try to reschedule any therapy sessions that are cancelled by either the patient or the therapist.
I understand that by coming to the office opting for in person therapyI 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. Name of Person i. Relationship to Patient. Therefore, failure to allow Southland to obtain these records may prevent your child from receiving services at Southland Therapy Services.
Suite H Savannah, Ga