Forms

Speech-Language

Associates, LLC

Christine Bebee Keener, M.A., CCC-SLP

Speech-Language Pathologist

Privacy Forms

           • HIPPA Privacy Form (click here)

            • HIPPA Privacy Form Acknowledgement (click here)







Christine Bebee Keener

Speech-Language Pathologist

489 N. Hwy. 287, Suite 201   •   Lafayette, CO 80026   •   www.SLAssoc.com   •  Chris@SLAssoc.com   •   303-926-4315


Patient Information



Name:

     

Today’s Date:

     

Date of Birth:

     



Sex: Male Female


Preferred contact method:

Home Phone:

     

Work Phone:

     

Cell Phone:

     

E-mail:

     

Address:

     

City:

     

State:

     

Zip:

     

Social Security Number:

     

Patient’s Occupation:

     

Patient’s Employer:

     

Parent/Spouse’s Name:

     

Parent/Spouse’s Employer:

     

Primary Care Physician’s Name:

     

Primary Care Physician’s Address:

     

City:

     

State:

     

Zip:

     

Person Responsible for Payment:

     

Address (if different from patient address):

     

Phone number (if different from patient phone):

     


How did you hear about this practice?

Doctor

Friend/Family Member

Self

Other


Insurance Information

Please give the receptionist a copy of your insurance card



Primary Insurance:

     

Policy Holder Name:

     

Group Number:

     

Phone Number:

     

Secondary Insurance:

     

Policy Holder Name:

     

Group Number:

     

Phone Number:

     




______________________________________                               ______________________________________     

Print Patient’s Name                                                                        Patient or Parent/Guardian Signature


_____________________________________                               _____________________________________  

Date                                                                                                  Relationship to Patient

 

Patient Information Forms

            * Patient History––Child (click here)

            • Treatment Authorization (click here)

            • Parent/Guardian Information (click here)

© Copyright 2013 by Christine Bebee Keener

 

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The following forms are available for your convenience. To expedite your initial appointment check-in, fill out the forms in the policy and forms section. Please bring them to your appointment. If you are coming for an evaluation, it is helpful if the forms can filled out and sent to Speech-Language Associates, LLC, at least two days before your appointment so that we may prepare for your evaluation.