Physician Referral Form: Voice & Speech Services

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Patient Information

Name *

Date of Birth *

YYYY

Phone Number *

Referral Information

Virtual Teletherapy Services Requested (please check all that apply) *

Voice Evaluation and Therapy

VCD/PVFM Evaluation and Therapy

Chronic Cough Evaluation and Therapy

Swallow Therapy (please note, MBS/VBS or FEES evaluation must be performed prior to onset of therapy, as Resonate does not feel virtual swallow evaluations are adequate to assess true swallow safety)

Pre-laryngectomy counseling session

Pre-radiation counseling for H&N Cancer

Alaryngeal Speech Rehabilitation Therapy

Gender Affirming Voice Therapy

Required

**Please note: resonance disorders and cleft palate evaluation and therapy should be directed to a VPD or Cleft Palate clinic. Resonate Voice and Speech defers to expertise in this field. Thank you.

Below are common diagnosis codes used for speech therapy treatment provided by Resonate. Please mark all diagnoses that apply. Any not listed, please include in the relevant medical history below. *

R49.0 Dysphonia

R49.0/J38.3 Muscle Tension Dysphonia

R49.1 Aphonia

R49.8 Other voice and resonance disorders (Vocal fatigue)

J04.0 Reflux laryngitis

J37.0 Chronic laryngitis

J38.01 Unilateral paralysis/paresis of vocal cord

J38.02 Bilateral paralysis/paresis of vocal cord

J38.1 Vocal cord polyp

J38.2 Bilateral vocal cord nodules

J38.3 Other diseases of the vocal cords (unspecified mass, cyst, stiffness, sulcus, bowed VF/atrophy, leukoplakia, etc.)

J38.4 Laryngeal edema or Reinke's Edema/polypoid corditis/polypoid degeneration of VFs

J38.5 laryngospasm, PVFM/VCD

J38.7 Other diseases of the larynx (presbylarynges, granuloma)

R13.12 Oropharyngeal Dysphagia

R13.14 Pharyngoesophageal Dysphagia

R47.8 Other speech disturbances (articulation or other speech issues following H&N cancer tx, for example)

R05 Cough

Other:

Required

Please include a brief summary of relevant medical history and impressions.

Referring Physician Name *

Physician, Nurse, and/or Office Administrator Names and Email (preferred contact(s) for exchange of information and reports)

By providing your initials below and submitting this form, you understand and agree that this form does not take the place of a signed order form, and is meant to provide important medical information and initiate communication among Resonate Voice and Speech Services, you (the physician or Practice), and the patient. You agree that the above information is true, and you have the authority to provide such information and make a referral for speech therapy services as the providing physician. Please note: a copy of your signed order form for speech therapy services may be requested at any time. *

Today's Date *

YYYY

Thank you for your referral! We are committed to the best of patient care; your trust in our work and support of our professional partnership is very important and much appreciated. You may leave the below fields blank if the information may be found on documentation provided.

Practice Phone Number

Practice Mailing Address

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Resonate Voice and Speech Services LLC. Report Abuse

Forms