REFERRAL FOR OUTPATIENT PEDIATRIC SPEECH / LANGUAGE PATHOLOGY
Fax to the RUSK INSTITUTE (212) 263-4555
Call the Department of Pediatric Speech-Language Pathology (212) 598-6248
Date:
Patient Name:
Patient Date of Birth:
Parent/Guardian Name (if appropriate):
Patient/ Guardian Telephone Number:
Patient Social Security Number:
Contact 1:(
)
Contact 2: (
)
PLEASE NOTE: If patient cannot be contacted directly, with whom should we speak?
Patient Address:
Primary Language:
Primary Insurance:
Secondary Insurance:
Policy Number:
Policy Number:
Medical Diagnosis:
Onset Date:
CVA
Cerebral Palsy
Spina Bifida
PDD/ASD
Encephalopathy
Other
Prescription for: (please Select)
Evaluation only
Insured Name:
Insured Name:
ICD9:
TBI
Seizure Disorder
Multiple Sclerosis
Brain Tumor
Developmental Delay
Evaluation and Treatment
Speech and Language Diagnosis
Aphasia 784.3
Cognitive Communication Disorder 438.0
Voice Disorder 784.4
Other
Dysarthria (Motor Speech Disorder) 784.5
Apraxia (Motor Speech Disorder) 784.69
Speech and Language Deficits 438.1
Articulation Disorder 315.39
Please visit www.nyuvoicecenter.org for Head and Neck SLP referrals
Physician’s Name (Please Print):
License Number:
Office Telephone:
Physician’s Signature:
UPIN:
NPI#:
Office Fax:
Rusk Institute of Rehabilitation
Hospital for Joint Diseases
301 East 17th Street, 4th Floor, New York, NY 10003 • Tel 212.598.6248 • Fax 212.263.4555