Speech Therapy Progress Report



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|6508 Gunn Highway ( Tampa, FL 33625 |

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Speech Therapy Progress Report

AUTHORIZATION PERIOD:_______________ to _________________

PCP:_______________________________ Patient:___________________________

Address:____________________________ Address:__________________________

____________________________________ ___________________________

Phone:_______________ Fax:_____________ Phone:___________________________

DOB:__________ Age:_____________

cc:___________________________________ Progress report date:______________

_____________________________________ Dx: _____________________________

Brief Medical History:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ProgressSummary:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

New Goals:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name_________________________

Page 2

Plan of Care:

( Language Stimulation ( Auditory Discrimination ( Adaptive Equipment

( Articulation ( Sign Language Trng. ( Oral Motor Skills

( Voice Training ( Communication Device ( Feeding

( Parent/ Teacher Trng. ( Other:________________ ( Other:______________________

( Equipment recommendations:________________________________________________

RECOMMENDATIONS

It is recommended that the above stated patient receive speech therapy:

(choose option #1 or #2; only use option #2 if the patient has Part C or private insurance funding).

1. Up to ______________treatment sessions within a six month period.

2. Frequency:_____________________________ times per week.

Duration:_6 months (unless otherwise stated) Other:_____________________________

( Treatment Sessions up to30 minutes.

( Treatment Sessions 30 – 60 minutes are medically necessary due to:_________________

_______________________________________________________________________.

_____________________________________ _________________

Therapist’s Signature Date

Dear Physician:

If you agree with the treatment plan above, please sign and date the report and mail/fax to Independent Living, Inc. Your signature will convert this report into a prescription.

_____________________________________ _________________

Physician’s Signature Date

_____________________________________

Medipass Auth. Number (if applicable)

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