<p> Where we play with a purpose</p><p>Acknowledgement of BCBS out-of-network status</p><p>□ I understand that Midlands Therapy Services, Inc (MTS), as are the majority of in home BabyNet providers in South Carolina, is an out of network provider for BCBS, BCBS state, Federal Employee program (FEP), Planned Administrators, BlueChoice, and all other BCBS PPO plans both in the state of SC and out of state. </p><p>□ I understand that because my child is in the BabyNet system and MTS is listed on my child’s IFSP and/or my child has Medicaid as a secondary insurance, I will not be financially responsible for anything BCBS or the other companies do not pay.</p><p>□ I understand that because MTS is out of network BCBS, I will need to give MTS a copy of the Explanation of Benefits (EOB) from my insurance company as they are received. </p><p>□ I understand that in the event my insurance company covers any of the services performed by MTS, I will sign over all payments/checks from BCBS and the other companies for dates of service provided by MTS. I will sign the back of the check received and write “for deposit only” underneath it. Please note: the payment may come separately and later than the EOB. </p><p>□ I understand that I will receive a phone call from MTS if it is determined that either the EOB and/or payment will continue on a monthly basis to set up an easy method to get these documents to MTS. </p><p>□ I understand that if I do not submit the EOBs and/or payments/checks to MTS in a timely manner (within 20 days of receipt), my child’s therapy may be put on hold. </p><p>□ I understand that I agreed to all of the above statements when enrolling with BabyNet. BabyNet will only be the payer of last resort for therapy services and requires proof of payment or denial (EOB) by my insurance company. </p><p>______Print name</p><p>______Signature Date</p><p>Midlands Therapy Services / P.O. Box, Lexington, SC 29071 / p: 803.359.3195 / f: 803.520.8398 midlandstherapysc.com</p>