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205740-533400SPEECH & LANGUAGE EVALUATIONPROGRESS SUMMARYAuthorization Period: ______________to______________ Patient: _________________________________PCP: ____________________________________DOB: ____________________________________Facility: _________________________________Parents: _________________________________Address: _________________________________Phone: __________________________________ ________________________________________Chronological Age: ________________________Phone: __________________________________Adjusted Age (if appropriate): _______________Fax: _____________________________________Date of Evaluation: ________________________CC: _____________________________________Therapist: _______________________________Medicaid #: ______________________________PROGRESS SUMMARY/STATUS CHANGE(Statement of effectiveness of therapeutic intervention)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PROGRESS ON PREVIOUS LONG/SHORT TERM GOALS/PLAN OF CARE FORMCHECKBOX See attachedATTENDANCE/ PARTICIPATIONAttendance during previous authorization period was: FORMCHECKBOX Good (>80%) FORMCHECKBOX Fair (60-80%) FORMCHECKBOX Poor (<60%) If Fair or Poor, explain: ___________________________________________________________________________________________________________________________________________________________________________________ FORMCHECKBOX Unable to document/data not available. Why: _________________________________________________________Patient participation/compliance during treatment sessions: FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorDescribe: ____________________________________________________________________________________________________________________________________________________________________________________________CAREGIVER TRAINING PROGRAMDescription of home program/caregiver training program implemented during previous authorization period: ______________________________________________________________________________________________________________________________________________________________________________________________________Adherence to caregiver training/ home exercise plan: FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorExplain: _______________________________________________________________________________________________________________________________________________________________________________________________Skilled therapy services continue to be indicated to carryout plan of care because: __________________________________________________________________________________________________________________________________UPDATED THERAPEUTIC PROGNOSIS FORMCHECKBOX Excellent FORMCHECKBOX Good FORMCHECKBOX Fair FORMCHECKBOX PoorGiven (mark all that apply): FORMCHECKBOX Responsiveness to therapeutic techniques FORMCHECKBOX Attendance and participation in therapy sessions FORMCHECKBOX Follow through with caregiver training program/ home exercise program FORMCHECKBOX Stable medical status FORMCHECKBOX Met optimal functional potential FORMCHECKBOX Unstable medical condition FORMCHECKBOX Other: __________________________________________________________________________________________Comments: ____________________________________________________________________________________________________________________________________________________________________________________________RECOMMENDATIONSRecommendations are as follows: FORMCHECKBOX Continue with Speech Therapy: FORMCHECKBOX See Attached Plan of Care for Long Term Goals and ObjectivesDuration: FORMCHECKBOX 6 Months FORMCHECKBOX 1 Year FORMCHECKBOX Other: Frequency: _ times per weekTime: FORMCHECKBOX 30 Minutes per session FORMCHECKBOX 45-60 Minutes per session are medically necessary: Reason: _____________________________________________________________________ FORMCHECKBOX Continued therapy is not recommended at this time. FORMCHECKBOX Due to change in rehabilitative potential transition to consultative services/home maintenance program recommended. FORMCHECKBOX Therapy is not indicated at this time but a Re-Evaluation is recommended in 6 months. FORMCHECKBOX Refer to: FORMCHECKBOX Physician for consideration of: ________________________________________________________ FORMCHECKBOX Developmental Pediatrician and/or Neurology FORMCHECKBOX Clinical Psychology Evaluation FORMCHECKBOX Applied Behavior Analysis FORMCHECKBOX Audiologist for: ________________________ FORMCHECKBOX Occupational Therapy FORMCHECKBOX Physical Therapy FORMCHECKBOX Other: _________________________________________________________________________________If you have any questions regarding this evaluation, please call Independent Living, Inc.- Pediatrics at (813) 963-6923. _______________________________________________________________________Therapist SignatureDate:FL License #: __________________________________________________________________________Supervisor Signature (if appropriate)DateFL License #: Dear Physician,If you agree with the treatment plan, please sign and date the report and mail/fax to Independent Living, Inc.- Pediatrics. Your signature will convert this report into a prescription._________________________________ __________________Physician Signature Date_________________________________Medipass Authorization Number (if applicable) ................
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