Physical therapy, occupational therapy, speech language pathology
Office: (361) 694-5678
Office fax: (361) 694-4821
Process for authorization and required documents will differ depending on payer. DCH will initiate authorization whenever possible.
Fax information required by referring physician:
- DCH patient referral form or physician’s order including physician’s signature
- Discipline ordered
- Evaluation and/or treatment specified
- Diagnosis, including ICD-10, supporting service requested
The etiological reason for a functional delay/disorder should be included among the diagnoses listed, if not present, services may be denied by payer.
- Demographic information or face sheet if not on the order
- Physician’s notes or H&P supporting requested services
- Insurance / Medicaid card (front and back)
- If order for Speech Language Pathology, please indicate type of evaluation and/or treatment and ensure related diagnosis:
- speech and language evaluation/treatment
- feeding evaluation/treatment
- video fluoroscopic swallow study/treatment
- Payer may require developmental screening documentation.
- Payer may require hearing screening or hearing testing results.
- Please indicate if speech and language evaluation is pending audiology results.
Patient must bring to appointment:
- List of current medications
- If the patient receives a questionnaire in the mail, complete and bring to appointment
- Patient must be accompanied to appointment by parent or guardian