Speech Therapy Progress Report
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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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