Adult Admission Packet - Speech Therapy Services, P.C.

PATIENT INFORMATION AND CONSENT

Name

First M.I. Last

Home Phone

Cell Number

Other Number

Contact Preference

Call
Text

Address

Street Address City State ZIP Code

Date of Birth

Doctor

Social Security Number

Primary Insurance Name

Insurance Number

Notice of Privacy Practices:
Speech Therapy Services, P.C. (STS) is required to provide our patients with a privacy notice regarding our legal duties and policies to protect your health privacy. Our practice is dedicated to maintaining the privacy of your individual identifiable health information (IIHI). This notice serves to inform you that STS uses your personal health information primarily for treatment, obtaining payment, and consulting with necessary health and educational members of this facility, including your doctor and his/her staff. You may obtain a complete copy of our office procedures and privacy practices at any time by contacting our office at the above location. If you have any questions or concerns, do not hesitate to call the speech therapy office at 246-4088. Consent for Treatment and Billing:
I have read and understand the process of speech therapy services, including evaluation, treatments, attendance policies, and privacy policies at STS. I give permission for STS to evaluate and provide speech therapy services to the patient listed above as indicated. I authorize the staff at STS to discuss protected health information with this patient’s caregivers, physicians and insurance company as needed to ensure coordination of services and quality care. I authorize STS to follow the necessary steps to bill this patient’s insurance company including the release of information to insurance providers as needed for the billing for services provided. I understand I am responsible for all charges at the time services are rendered and if my insurance is billed, I am responsible for all unpaid balances.

Signature

Print Name

Case History

Thank you, for choosing Speech Therapy Services, P. C. We kindly request that you fill out all the necessary information for our therapists to complete a comprehensive evaluation.

Name

First Last

Address

Street Address City State ZIP Code

Date of Birth

Phone

Occupation

Business Phone

Employer

Referred By

Phone

Address

Street Address City State ZIP Code

Family Physician

Phone

Address

Street Address City State ZIP Code

Maritial Status

Single
Married
Widowed
Divorced

Spouse's Name

Children

Include their name, gender, and age.

Who Lives In the Home?

What languages do you speak?

What is your dominant language?

What is the highest grade, diploma, or degree you earned?

General Information

Describe your speech language problem.

List current diagnosis/current medical findings.

What do you think may have caused the problem?

Has the problem changed since it was first noticed?

Yes
No

How?

Have you seen any other speech-language specialists?

Yes
No

When and How Long?

What were the conclusions or suggestions?

Have you received any speech therapy while homebound?

Yes
No

Have you seen any other specialist?

(physicians, audiologists, psychologists, neurologists, etc)

Yes
No

Please indicate the type of specialist, when you were seen and the specialist’s conclusions or suggestions.

Are there any other speech, language or hearing problems in your family?

Yes
No

Please describe

Medical History

Provide the approximate ages at which YOU suffered the following illnesses and/or conditions:

Allergies

Asthma

Colds

Dizziness

Draining Ear

Ear Infections

Encephalitis

Headaches

Hearing Loss

High Fever

Influenza

Mastoiditis

Meningitis

Noise Exposure

Otosclerosis

Pneumonia

Seizures

Sinusitis

Tinnitus

Other

Do you have any eating or swallowing difficulties?

Yes
No

Describe

List all medications you are taking

Are you having any negative reactions to these medications?

Yes
No

Describe

Describe any major surgeries, operations or hospitalizations and when they occurred.

Describe any major accidents and when they occurred.

Additional Information

Please provide any additional information that might be helpful in the evaluation or remediation process.

Person completing form

Relationship to patient

Signature

On the day of the evaluation, you will need:

Insurance information
Prescription from the physician ordering the therapy evaluation (if MD did not fax it directly to Speech Therapy Services.)
Copy of any evaluations done by specialists (psychologist, neurologist, etc.)