Parent / Guardian's Information

Home Address


Insurance Information




I herby authorize Capital City Therapy Group LLC., to release and/or obtain any/all medical information/records and educational information for my child from the date I sign this consent until discharge. I understand that this information may be released in any of the following ways: fax, email, direct mail, wireless communication or by telephone. I authorize Capital City Therapy Group 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 Capital City Therapy Group 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 Capital Therapy Group for services rendered to me. The inability to collect necessary information may cause denial of eligibility for services. Families have the right to request a copy of any information that is disclosed or obtained.

Contact Information

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

Email Consent for Correspondence

I acknowledge that Capital City Therapy Group can contact me through email for appointments and other therapy updates. I understand this risk involved with email communications. I may withdraw this consent at any time by written communication with the office manager.


I hereby consent to and authorize Capital City Therapy Group, and the contracting therapist in charge of my child's care, to perform evaluations and/or implement treatment plans deemed necessary in his/her professional opinion; however, no guarantees can be made regarding treatment outcomes. 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. All of our therapists are Licensed Professionals with the South Carolina LLR Board. Your child may be seen by an SLP-A (speech language pathology assistant) or a COTA (certified occupational therapy assistant) who is directly supervised according to state regulations. Please note that we are a teaching facility and that your child may be treated by a student, with direct supervision from a licensed therapist. 

By signing this form, I have read the above and agree to these policies. I hereby give consent to Capital City Therapy Group to provide services and bill my insurance as needed for my child.

Signature *

Agreement Regarding Insurance and Fees

I understand that Capital City Therapy Group is only in-network with SC Medicaid, SC Medicaid MCOs, and Blue Cross Blue Shield. These plans include SC Medicaid Fee-for-service, First Choice by Select Health, Molina, Absolute Total Care, Healthy Blue Medicaid, Humana Medicaid, BabyNet and BCBS. CCTG will file claims to these plans. 

I understand that CCTG is not in-network with any private insurance group, other than Blue Cross Blue Shield, and that I am responsible for all fees (self-pay, co-pays, coinsurance and amounts not covered by insurance) at time of service. 

I understand it is my responsibility to verify my out-of-network benefits prior to beginning services and obtaining reimbursement from my insurance provider .

I have read the Agreement and Policy above. I understand the policy and by my signature below I agree to be bound by its terms in association with outpatient services provided to me by Capital City Therapy Group.