We want your experience with us to be as pleasant as possible!
In order to save you time when you arrive, please fill out the following forms before your first visit.
Your first appointment will last about 1 hour and will conclude with a plan for treatment. Please bring any questions you may have to this appointment. It’s a good idea to write your questions down so that we may address all of your concerns.

If you are planning on using insurance for your sessions, please contact your insurance provider to get these questions answered at the start. We will submit paperwork on your behalf directly to the insurance providers, but we also suggest you reach out directly to your insurance provide and ask these questions:

  • Will they cover Speech Therapy?
  • Do you have a co-pay/co-insurance for these visits?
  • Do you have a deductible that needs to be fulfilled?
  • How many visits are you allowed for Speech Therapy treatment per year?
  • Do you need a doctor’s order or referral?
  • Do you need preauthorization?

We collect the copayments, coinsurance and deductibles at the time of service. Please arrive about 10 minutes before your appointment so that we can collect your information and get you in to see the therapist as soon as possible.

The following is a checklist that needs to be completed at the time of your first appointment:

  • Patient Information Sheet
  • Treatment Authorization Sheet
  • Payment Policy
  • Authorization for submitting insurance payment information
  • Acknowledgement of receipt of HIPAA Privacy Notice
  • Credit Card Authorization Form (optional)
  • Thank you for choosing Frederick SLP for your speech therapy. Let us know if you have any questions before you arrive. We look forward to meeting you!


Step 1 of 3




  • PLEASE DO NOT ENTER “SEE CARD” in Lieu of providing the required information!
  • Please be ready to also present your insurance card and ID to receptionist so that copies can be added to your file


By signing below you agree that all of the information provided here is up to date and correct to the best of your knowledge.


  • By signing the following agreement, you are allowing Frederick SLP to submit claims for services to the respective insurance provider on your behalf.
  • Signature and information included here also represent your consent for the provider to pay Frederick SLP directly for her services where appropriate.
  • Any deductible or co-pay is applicable according to the terms of your individual policy.
  • If there is a balance that is outstanding after submission and any subsequent attempts at insurance coverage, the person responsible for the payment will be expected to pay Frederick SLP in full.

I request that payment of authorized (insurance provider)

benefits be made either to me or on my behalf to Frederick SLP for any services furnished to me by Frederick SLP. I authorize any holder of medical information about me to release to the (insurance provider)

and its agents any information needed to determine these benefits or the benefits payable for related service.