Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering the member name and member ID number. This information is crucial for identifying the individual requesting therapy services.
3. Input the facility name where therapy will take place. Ensure that this is accurate to facilitate communication and service delivery.
4. Indicate whether a previous prescription for the diagnosed condition exists by selecting 'Yes' or 'No'.
5. Fill in the date of birth (DOB) of the member and the diagnosis (Dx) for which therapy is requested.
6. If applicable, provide the facility ID number.
7. Answer if there are any other diagnoses by selecting 'Yes' or 'No'.
8. Provide clinical assessments by entering the number of previous treatments received and the number of visits requested.
9. If treatment coverage beyond 30 visits is being requested, indicate that as well.
10. Enter the date of the report and the ICD code associated with the diagnosis.
11. Complete the facility contact information, including the facility phone number and facility fax number.
12. Document the date of the first treating visit and the estimated discharge date.
13. Assess and record various clinical evaluation metrics such as comprehension, expression, cognition, speech, swallowing, and communication skills for household management and community interaction.
14. Set clinical goals and expected functional outcomes by detailing treatments and objectives within the provided space.
15. Finally, complete the provider's information by entering their name, ID number, indicating who requested the authorization, and obtaining the necessary signature.
16. After filling in all required fields, ensure all details are correct, then save changes, download, print, or share the completed form as needed.

Complete the Speech Therapy Authorization Form online today to ensure timely access to necessary services.