BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...
BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...
BadgerCare Plus & Medicaid SSI Provider Manual - Group Health ...
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Speech Therapy<br />
Request Form<br />
Patient’s Name:<br />
DOB: ________________ ID#_____________________<br />
Ordering Physician:<br />
Clinic: ________________________________________<br />
Therapy <strong>Provider</strong>:<br />
Name/Specialty/Clinic<br />
Phone #: ___________________________<br />
Tax ID: _______________ Fax#:___________________<br />
Diagnosis: ICD-9: Date of Initial Eval:<br />
Is this a Worker’s Comp or accident case? Yes No<br />
Dates of service requested: __________________________________________________________<br />
Number of visits requested: __________________________________________________________<br />
PLEASE SEND EVALUATION FOR FIRST REQUEST ONLY.<br />
ADDITIONAL REQUESTS WILL NEED ONLY THE MOST RECENT VISIT NOTE.<br />
<strong>Provider</strong> Contact Name Phone # Date<br />
A Speech Therapy Evaluation will be required after the initial evaluation. If additional visits are needed,<br />
authorization is required prior to continuing. Services must be prescribed and monitored by a Primary Care<br />
Physician or Specialty Physician to be considered a covered benefit.<br />
Revised: 3/15/12 <strong>Health</strong> Management Fax: (715) 552-7202<br />
GHC11043