[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-285787-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-285787-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","cares-therapy-clinic-patient-referral-form","CARES Therapy Clinic - Patient Referral Form","","This document serves as the official Patient Referral Form for the CARES Therapy Clinic, a student-managed, non-profit organization providing free occupational, physical, and speech therapy services to uninsured adults. The form facilitates the request for medical necessity for specific therapies, including Physical Therapy, Occupational Therapy, and Speech Therapy. It captures essential patient information, clinical diagnoses, requested treatment modalities such as exercise programs, modalities, and adaptive equipment, and requires physician authorization. The document also provides critical logistical details, including clinic operating hours, contact information, and location, ensuring streamlined communication between referring medical professionals and the clinic staff to support the continuity of patient care in the Charleston, South Carolina 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is eligible to receive services at the CARES Therapy Clinic?","Question",{"text":63,"@type":64},"The clinic provides free occupational, physical, and speech therapy services specifically to adults who do not have health insurance.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What are the operating hours for the CARES Therapy Clinic?",{"text":68,"@type":64},"The clinic sees clients two nights per week, from 6-8pm: Tuesday for orthopedic diagnoses and Wednesday for neurological diagnoses.",{"name":70,"@type":61,"acceptedAnswer":71},"What information must a referring physician provide on the form?",{"text":72,"@type":64},"The referring physician must provide the patient's information, specify the type of therapy requested, confirm the duration of treatment, list the medical diagnosis, and provide a signature along with contact 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clients two nights per week from 6-8pm: Tuesday for ortho diagnoses and Wednesday for neuro  \ndiagnoses.  \nRequest for Physical Therapy or Occupational Therapy Letter of Medical Necessity  \nDate of Request:  /  /   \nPatient Name:   Patient Phone Number:   Patient Address:   Patient Date of Birth:   \nReferring Clinic, Physician and/or Medical Student/Physician’s Assistant Student:  \nReferral for:  Physical Therapy  Occupational Therapy  Speech Therapy  \nDuration of treatment, to be determined by therapist, for a maximum 365 days?  Yes  No If No, Duration of treatment:    \nNOTE: Frequency of treatment will be a maximum of once per week due to CARES Clinic hours  \nEvaluate and Treat  \nExercise Program: Range of Motion, Strengthening, Joint Mobilization Modalities: Ultrasound, Electrical Stimulation, Moist Heat/Cryotherapy, TENS  \nAdaptive Equipment: Orthotics, Bracing, Taping Assistance with self care and daily activities  \nMedical Diagnosis:  Special Treatment Considerations:   \n_______________________________________________________________________  \n_______________________________________________________________________  \nPhysician/SMD/SPA Signature:  \nName printed:  \nPhysician/Clinic Contact Number: Fax number:  \nTo schedule an appointment at CARES Clinic Downtown:  \nPhone: 843.792.8019  \nFax: 843-792-2829  \nCARES Clinic Downtown is located in the Rutledge Garage on Ashley Avenue.  \n158 Ashley Ave  \nCharleston, SC","cbCaiuo8UgHua4pg","https://ap.wps.com/l/cbCaiuo8UgHua4pg","pdf",1114571,"English","# Patient and Referring Information\n## Treatment Request Details\n## Clinical Modalities and Diagnosis\n## Physician Authorization and Clinic Contact Information","[{\"question\":\"Who is eligible to receive services at the CARES Therapy Clinic?\",\"answer\":\"The clinic provides free occupational, physical, and speech therapy services specifically to adults who do not have health insurance.\"},{\"question\":\"What are the operating hours for the CARES Therapy Clinic?\",\"answer\":\"The clinic sees clients two nights per week, from 6-8pm: Tuesday for orthopedic diagnoses and Wednesday for neurological diagnoses.\"},{\"question\":\"What information must a referring physician provide on the form?\",\"answer\":\"The referring physician must provide the patient's information, specify the type of therapy requested, confirm the duration of treatment, list the medical diagnosis, and provide a signature along with contact details.\"}]","CARES Therapy Clinic - Patient Referral Form | PDF",1789630318]