Registration

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The following are forms that Speech Language Development, SLP P.C. needs prior to the initial evaluation. Please view them, print them out and fill them out to the best of your ability, in order that they can be completed before you come in for the evaluation. Although it is your responsibility to know your insurance coverage, including co-payments and how many visits you are authorized, we will gladly help you in obtaining this information any way that we can.

Please bring the following documents with you at the time of your appointment for an evaluation:

Patient registration form

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Case history form. Child

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Case history form. Adult

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Authorization to release/exchange information

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Assignment of Benefit Form-for clients coming through insurance and private pay only.

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Payment Options

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Patient Notification and Billing Cancellation – for clients with private pay only

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Patient Responsibility for Payment

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HIPPA Notice 1

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HIPPA Notice 2

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HIPPA Patient Info Consent form 3

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Consent for Video/Audio taping

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Schedule for Fall, Winter, Spring

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Schedule for Summer

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