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Forms
Please fill out the forms available for download below &
Email them after completion to Michelle Azor Burgess at:
mburgess@speechpathclinic.com
Billing & Insurance Procedures FAQ
Payment Policies
Intake Paperwork
1. Client information form
2. ST-OT Case History Form
4. Receipt of Privacy Practices-HIPPA
6. Policies and Procedures
8. Release of Info Authorization
10. Sick child policy.pdf
12. Application for end of month billing
1a. TEIS Transition
3. Notice of Privacy Practices-HIPPA
5. Attendance and Participation Policy
7. Consent for Assessment
9. Picture release
11. Fee Schedule
13. Billflash enrollment or declination
14. SpeechPath Clinic Billing and Insura