SpeechPath Outpatient

SpeechPath

Outpatient Clinic

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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

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