SPEECH THERAPY PATIENT
REFERRAL & PRESCRIPTION FORM
747 52nd St., Oakland, CA 94609 510-428-3000 • www.childrenshospitaloakland.org
DATE __________________________________________________
PATIENT INFORMATION REFERRING MD CONTACT INFORMATION
Patient’s First Name _______________________________________ Referring MD _____________________________________________
Last Name _______________________________________________ Best way to reach me is by Phone Fax Pager
DOB _____/_____/_____ Gender Female Male Phone ( ) ____________________________________________
Parent/Guardian Name_____________________________________ Fax ( ) _______________________________________________
DOB _____/_____/_____ Relationship ________________________ Office Name _____________________________________________
Street Address ___________________________________________ Office Street Address ______________________________________
City___________________________State______Zip ____________ City___________________________State______Zip ____________
Daytime Phone ( ) _____________________________________ Pager ( ) _____________________________________________
Alternate Phone ( ) ____________________________________
DIAGNOSIS
Interpreter needed? No Yes: Language ____________________ Diagnosis ICD-10 code _____________________________________
Reason for visit:
INSURANCE INFORMATION Speech/Language Impairment due to recent
cognitive/neurological insult
Subscriber Name _________________________________________ Speech/Language delay
Augmentative communication evaluation
DOB _____/_____/_____
Feeding/failure to thrive
Health Plan ______________________________________________
Other _________________________________________________
Authorization #___________________________________________
________________________________________________________
Group # _________________________________________________ Brief Medical History ______________________________________
Member ID ______________________________________________ ________________________________________________________
Secondary Insurance, if any _________________________________ ________________________________________________________
Activity or other medical precautions or considerations? No Yes (Describe/define) ____________________________________________
____________________________________________________________________________________________________________________
Speech & Language Therapy Evaluation & Treatment
Feeding/Dysphagia Evaluation
Videoswallow study
Other _____________________________________________________________________________________________________________
Anticipated frequency/duration__________________________________________________________________________________________
Special instructions ___________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Physician Signature ___________________________________________________________________________________________________
Name of Physician (print) ______________________________________________________________________________________________
LIcense # ____________________________________________________________________________________________________________
2014
COMMONLY USED CPT AND HCPCS CODES FOR SPEECH THERAPY SERVICES:
CPT (Used for PPOs, HMOs, self-pay)
Code Description
Speech Language Evaluation 92523 Evaluation of speech sound production (e.g., articulation,
phonological process, apraxia, dysarthria); with evaluation of
language comprehension and expression (e.g., receptive and
expressive language
Dysphagia Evaluation 92610 Evaluation of oral and pharyngeal swallowing function
Fluoroscopic Evaluation of Swallowing 92611 Motion fluoroscopic evaluation of swallowing function by cine or
video recording.
Speech Therapy Treatments 92507 Treatment of speech, language, voice, communication, and/or
auditory processing disorder, individual
97532 Cognitive skills: Development of cognitive skills to improve attention,
memory, problem solving, direct one-on-one, each 15 minutes
92526 Dysphagia treatment: Treatment of swallowing dysfunction and/or
oral function for feeding
HCPCS (Used for Medi-Cal, CCS, many government funded HMOs, etc)
Code Description
Speech Therapy Evaluation (need to X4300, Language Evaluation
request both codes) and
X4301 Speech Evaluation
Speech Therapy Treatments X4303 Speech-language therapy, individual, per hour (following procedures
x4300 or x4301
X4304 Speech-language therapy, individual, ½ hour
2014
