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Speech Referral Form

The document is a referral form for speech therapy that includes sections for patient information, referring doctor contact information, diagnosis, insurance information, and commonly used CPT and HCPCS codes for speech therapy services. It requests information such as the patient's name, date of birth, diagnosis, insurance details, and refers the patient for a speech and language therapy evaluation and treatment.

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Ruby Gupta
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41 views2 pages

Speech Referral Form

The document is a referral form for speech therapy that includes sections for patient information, referring doctor contact information, diagnosis, insurance information, and commonly used CPT and HCPCS codes for speech therapy services. It requests information such as the patient's name, date of birth, diagnosis, insurance details, and refers the patient for a speech and language therapy evaluation and treatment.

Uploaded by

Ruby Gupta
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SPEECH THERAPY PATIENT

REFERRAL & PRESCRIPTION FORM


747 52nd St., Oakland, CA 94609 510-428-3000 • www.childrenshospitaloakland.org

DATE __________________________________________________

PATIENT INFORMATION REFERRING MD CONTACT INFORMATION

Patient’s First Name _______________________________________ Referring MD _____________________________________________

Last Name _______________________________________________ Best way to reach me is by Phone Fax Pager

DOB _____/_____/_____ Gender Female Male Phone ( ) ____________________________________________

Parent/Guardian Name_____________________________________ Fax ( ) _______________________________________________

DOB _____/_____/_____ Relationship ________________________ Office Name _____________________________________________

Street Address ___________________________________________ Office Street Address ______________________________________

City___________________________State______Zip ____________ City___________________________State______Zip ____________

Daytime Phone ( ) _____________________________________ Pager ( ) _____________________________________________

Alternate Phone ( ) ____________________________________


DIAGNOSIS
Interpreter needed? No Yes: Language ____________________ Diagnosis ICD-10 code _____________________________________
Reason for visit:
INSURANCE INFORMATION Speech/Language Impairment due to recent
cognitive/neurological insult
Subscriber Name _________________________________________ Speech/Language delay
Augmentative communication evaluation
DOB _____/_____/_____
Feeding/failure to thrive
Health Plan ______________________________________________
Other _________________________________________________
Authorization #___________________________________________
________________________________________________________
Group # _________________________________________________ Brief Medical History ______________________________________

Member ID ______________________________________________ ________________________________________________________

Secondary Insurance, if any _________________________________ ________________________________________________________

Activity or other medical precautions or considerations? No Yes (Describe/define) ____________________________________________

____________________________________________________________________________________________________________________

Speech & Language Therapy Evaluation & Treatment


Feeding/Dysphagia Evaluation
Videoswallow study

Other _____________________________________________________________________________________________________________

Anticipated frequency/duration__________________________________________________________________________________________

Special instructions ___________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Physician Signature ___________________________________________________________________________________________________

Name of Physician (print) ______________________________________________________________________________________________

LIcense # ____________________________________________________________________________________________________________

2014
COMMONLY USED CPT AND HCPCS CODES FOR SPEECH THERAPY SERVICES:

CPT (Used for PPOs, HMOs, self-pay)

Code Description

Speech Language Evaluation 92523 Evaluation of speech sound production (e.g., articulation,
phonological process, apraxia, dysarthria); with evaluation of
language comprehension and expression (e.g., receptive and
expressive language

Dysphagia Evaluation 92610 Evaluation of oral and pharyngeal swallowing function

Fluoroscopic Evaluation of Swallowing 92611 Motion fluoroscopic evaluation of swallowing function by cine or
video recording.

Speech Therapy Treatments 92507 Treatment of speech, language, voice, communication, and/or
auditory processing disorder, individual

97532 Cognitive skills: Development of cognitive skills to improve attention,


memory, problem solving, direct one-on-one, each 15 minutes

92526 Dysphagia treatment: Treatment of swallowing dysfunction and/or


oral function for feeding

HCPCS (Used for Medi-Cal, CCS, many government funded HMOs, etc)

Code Description

Speech Therapy Evaluation (need to X4300, Language Evaluation


request both codes) and

X4301 Speech Evaluation

Speech Therapy Treatments X4303 Speech-language therapy, individual, per hour (following procedures
x4300 or x4301

X4304 Speech-language therapy, individual, ½ hour

2014

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