Medical Rehabilitation Division Referral for Therapy Services

Medical Rehabilitation Division Referral for Therapy Services

Please complete this form and attach a current prescription for therapy services. Please note that referrals cannot be processed until both the Referral for Therapy Services form and prescription are received. Please contact Melissa Griffin, Director of Medical Rehabilitation,with any questions at (803) 627-3857. We look forward to working with you!
Service (s) Requested

Occupational Therapy Physical Therapy Speech Therapy
BabyNet Eligible:

Yes No
Child Name

First Name Last Name
DOB

Month Day Year
Child's Date of Birth
Gender:

Male Female
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Therapy at home:

Yes No
If no, address of visit location:
Guardian Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Interpreter Required:

Yes No
If Yes, Interpreter Name and Phone Number:
Primary Physician:
Physician Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Physician Phone Number

Area Code Phone Number
Physician Fax:

Area Code Phone Number
Insurance Permitted:

Yes No
Insurance Coverage: (Check all that apply)

Private Insurance Medicaid BabyNet
Insurance Company:
Policy Number:
Policy Holder:
Policy Holder DOB:

Month Day Year
Date
Medicaid Number
MCO

Yes No
If yes, MCO Name
Has this child been previously evaluated

Yes No
If yes, what was the date of the most recent evaluation: (please include a copy of the evaluation)

Month Day Year
Date
Early Interventionist (EI):
EI Agency:
EI Phone:

Area Code Phone Number
EI Fax:

Area Code Phone Number
EI Email:
example@example.com
EI Signature:

Clear
Date of Referral:

Month Day Year
Date
Upload Prescription

Browse Files

Cancel of
Prescription Included:

Yes No
Should be Empty: