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:
Doctor’s prescription with diagnosis and length of treatment (dated)
Previous reports/evaluations/ IEPs (if any)
Patient registration form
Case history form. Child
Case history form. Adult
Authorization to release/exchange information
Assignment of Benefit Form-for clients coming through insurance and private pay only.
Payment Options
Patient Notification and Billing Cancellation – for clients with private pay only
Patient Responsibility for Payment
HIPPA Notice 1
HIPPA Notice 2
HIPPA Patient Info Consent form 3
Consent for Video/Audio taping
Schedule for Fall, Winter, Spring
Schedule for Summer
