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Medicaid or ID Number
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Date
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Diagnoses:
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Comments
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Last PCP Visit
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AAC?
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Comments
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Phygbnmbgjh
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Comments
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Sahfnv bhhfgkjhgngv
|
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Activities:
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Comment
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Mental Status:
• • •
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Comments
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Prognosis:
• • •
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Comments
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Rehab Potential:
• • •
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Comments
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Speech Therapy Recommendations:
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Comments
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Speech Therapy Duration:
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Comments
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Modalities:
• • •
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Initial Behavior/Response:
|
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LANGUAGE
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Tests/Measures Used For Assessment of Language:
• • •
|
|
Results of Language Assessment:
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ARTICULATION
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Measures Used For Assessment of Speech/Oral func
• • •
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articulation skills could
• • •
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Results of Speech and Oral Motor Assessment:
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OTHER
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Feeding Skills:
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Fluency and Voice:
|
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Hearing and Vision:
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Comments
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|
Assistive and Adaptive Devices:
• • •
|
Comments
|
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Sfgfvb njhetdgb vhdhfbv?
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Other
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GOALS AND PLAN
|
Assdfvbn
/
|
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Long Term Goals: will clearly communicate
|
Long Term Goals
|
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Short Term Goals: will clearly communicate
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Short Term Goals
|
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will gain appropriate weight
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Atghrbgvn:?
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Summary
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Speech/Language Delay
|
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Discharge Plan:
|
and
• • •
|
|
will benefit from skilled speech therapy services
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Overall delay is-
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Intervention Plan:
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Diagnosis
|
|
yhdetfhydubg
|
|
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MD Signature
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TP2
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TP2 Page 2
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Superior Prior Auth
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TP1 - Betsy
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Additional Documents
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