South Carolina Patient Form

South Carolina Patient Form
Caregiver Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Alternative Number
Select ALL insurance plans that cover the child*

ABSOLUTE TOTAL CAREAETNABLUE CROSS BLUE SHIELDCIGNAFIRST CHOICE (SELECT HEALTH)HEALTHY BLUEHUMANAMAGELLANMOLINAUBH/OPTUMTRICARE EAST WPS CERTIFIEDOther
How did you hear about us?*

GoogleFacebookProvider ReferralSchool or Day Care CenterFriend or FamilyDoctor or PediatricianInsurance CompanyOther
Name of the Full Spectrum ABA provider that refereed you:
Type of Insurance*

MedicaidPrivate
Name of Insurance
Name of Private Insurance Company

ABSOLUTE TOTAL CAREAETNABLUE CROSS BLUE SHIELDCIGNAFIRST CHOICE (SELECT HEALTH)HEALTHY BLUEHUMANAMAGELLANMOLINAUBH/OPTUMTRICARE EAST WPS CERTIFIEDOther
Insurance ID
Insurance Subscriber Name (Policyholder)

First NameLast Name
Date of Birth of Insurance Subscriber (Policyholder)

MonthDayYear
Date
Patient's Name*

First NameMiddle NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Patient's Sex*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select your County*
County

Abbeville CountyAiken CountyAllendale CountyAnderson CountyBamberg CountyBarnwell CountyBeaufort CountyBerkeley CountyCalhoun CountyCharleston CountyCherokee CountyChester CountyChesterfield CountyClarendon CountyColleton CountyDarlington CountyDillon CountyDorchester CountyEdgefield CountyFairfield CountyFlorence CountyGeorgetown CountyGreenville CountyGreenwood CountyHampton CountyHorry CountyJasper CountyKershaw CountyLancaster CountyLaurens CountyLee CountyLexington CountyMarion CountyMarlboro CountyMcCormick CountyNewberry CountyOconee CountyOrangeburg CountyPickens CountyRichland CountySaluda CountySpartanburg CountySumter CountyUnion CountyWilliamsburg CountyYork CountyOther
Check all the behavioral concerns that apply to your child:*

ElopementPhysical AggressionTantrumTask RefusalSelf Injurious BehaviorProperty DestructionSpittingMouthing ObjectsDisrobingVerbal AggressionOther
Does the family speaks fluent English or primarily Spanish?*

Fluent EnglishFluent SpanishOther
Diagnosis Code
The patient is currently attending:*

SchoolDay CareHome SchoolOther
Name of the Patient School or Day Care Center
Doctor's Name and Practice*
Doctors' Office Phone Number*
Doctor's Mailing Address
Delivery Method*

MailPhoneFaxEmail
Choose "I Authorize ALL" or select individually*

I authorize ALL Health information to be disclosedIndividual Education Plan (IEP)Psych Educ. AssessmentReport Cards/TranscriptsBehavioral ReportSpecial ReportPsychological EvaluationMedication Management VisitsSpeech/Language EvaluationHearing ScreeningMedical History and Immunization RecordNeurology ReportPsychiatric EvaluationProgress NotesClient Information SheetIndividualized TreatmentTreatment Plan ReviewsPsychosocial EvaluationBehavioral ProgramDischarge SummaryProgress Summary
Expiration*

One YearTwo yearsType a Date: mm/dd/year
Purpose of the Release of Information*

At the request of the IndividualAssessmentTreatment
Coordination*

Disability DeterminationTo obtain information for Brief Behavioral Health Status ExamOther - Please Specify
Case Manager
Is there a case manager or other support person assisting you with service coordination?*

YesNo
Case Manager Name

First NameLast Name
Case Manager Phone Number
Please enter a valid phone number.
Do you give Full Spectrum ABA permission to discuss your child's needs and services with the person named above?

YesNo
1) I understand that Full Spectrum Behavior Analysis, LLC cannot guarantee that the Recipient will not re-disclose my health information to a third party. The Recipient may not be subject to federal laws governing privacy of health information. 2) I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from Full Spectrum Behavior Analysis, LLC. 3) I understand that I may revoke this Authorization in writing at any time, however, l cannot revoke authorization for action that has already been taken. I further understand that I must provide any notice of revocation in writing to the Business Office at the address listed above.
Copy of Insurance Card(s) - FRONT and BACK

Cancelof
Physician’s referral (Script)

Cancelof
BASP Start

MonthDayYear
Date
BASP End

MonthDayYear
Date
Discharge Date

MonthDayYear
Date
Comprehensive Diagnostic Report

Cancelof
Billing Approval Date

MonthDayYear
Date
I-Observation

MonthDayYear
Date
Please E-Sign and Click Submit*

Clear

South Carolina Patient Form

Case Manager