Rusk Rehabilitation
Speech-Language Pathology Department
Neurogenic Communication Disorders
Voice Disorders
Swallowing Disorders Center
REFERRAL FOR ADULT SPEECH, LANGUAGE, VOICE & SWALLOWING SERVICES
COMPLETE and FAX to the Rusk Intake Office at (212) 263-0113
ATTACH THE PATIENT’S FACE SHEET FOR INSURANCE & BILLING INFORMATION
Patient Name: _______________________________
Date of Birth: ____________________________
Phone #: ___________________________________
E-mail: _________________________________
A medical diagnosis is required for registration
***Medical Diagnosis: ________________________________
Onset Date: ____________
ICD 9 Codes (Please include ALL codes that apply):
VOICE SERVICES
_____ Dysphonia 784.42
_____ Vocal fold nodules/cyst/granuloma 478.5
_____ Vocal fold polyp 478.4
_____ VF paralysis (Uni:478.32/Bil:478.34)
_____ VF paresis (Uni:478.31/Bil:478.33)
_____ VF edema 478.6
_____ PVFM 478.75
_____ Aphonia 784.41
_____TEP Evaluation
_____ Alaryngeal Treatment
Prescription:
Evaluate only ______
Evaluate & treat as needed_______
DYSPHAGIA SERVICES
_____ Dysphagia oral phase 787.21
_____ Dysphagia oropharyngeal 787.22
_____ Dysphagia pharyngeal phase 787.23
_____ Dysphagia pharyngoesophageal 787.24
_____ Other dysphagia 787.29
_____ Choking sensation 784.99
_____ Cough 786.2
_____Hx of aspiration/aspiration pneumonia 507
_____Failure to thrive 783.41
COMMUNICATION SERVICES
_____Cognitive Deficits 438.0
_____Aphasia 784.1
_____ Dysarthria (motor speech disorder) 784.5
_____Speech and Language Deficits 438.1
_____Apraxia of Speech 784.69
_____ Other
SLP may perform as indicated:
____Videofluoroscopic Swallowing Study (VFSS)
____Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
____Diagnostic Laryngoscopy with Stroboscopy
Physician’s Name (Please Print): _________________________________________________
License Number: ______________ UPIN: __________
NPI#: ____________________
Office Telephone: _____________________ Office Fax: ____________________
Physician’s Signature: _________________________________________
Rusk Rehabilitation at the Ambulatory Care Center • NYU Langone Medical Center
240 East 38th Street, New York, NY 10016 • 212-263-6033, prompts 3 then 7