Referral Form - Speak Speech Therapy

Referral Form

Step 1 of 4 -

25%

Client Information

First Name

Last Name

Diagnosis

Date of Birth

Gender

Male

Female

Therapy Setting

Clinic

Teletherapy

Center

Treating Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Therapy Availability

Parent/Guardian Information

First Name

Last Name

Mobile Phone

Home Phone

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Emergency Contact

Relationship

Cell Phone

Insurance Information

Do you have Medicaid?

Yes

Insurance Name

Insurance ID

Group Number

Policy Holder Name

Date of Birth

Physician Information

Physician Name

Phone

Fax

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Last day patient was seen by PCP

Do you have a speech referral for your child?

Yes

Child has completed a hearing screen within the last year?

Yes

Disclaimer Notice

Verification of benefits is a courtesy service provided by Speak Speech Therapy. This quote of benefits and/or authorization does not guarantee payment or how benefits will be applied. Payment of benefits is subject to all terms, conditions, visit limitations, and exclusions of the member's contract at the time services are rendered. Services rendered by other providers may affect visit limits and costs.

We must have a credit card on file before we schedule for the Initial Evaluation. The parent/caregiver is ultimately responsible for independently verifying and tracking benefits for services by Speak Speech Therapy.

The therapist evaluating may or may not be the same as the therapist treating. This depends on the patient's location and availability.

Thank you for choosing Speak Speech Therapy as your provider.