Thank you for choosing the Appalachian State University Communication Disorders Clinic.  We are proud of the services that we provide and are dedicated to helping you address the questions you have concerning a speech, language or hearing problem.

Below you will find the following forms to be opened using Microsoft Word, completed and returned to our office:

• Background Information Form - Please choose the appropriate form and complete only those sections that apply to you or your child's problem.
  • Child 0-5 years of age
  • Child 6-17 years of age
  • Adult
  • Child/adult with reading difficulties (A child or adult with literacy/reading difficulties must have a psychoeducational evaluation on file in the Clinic office before the evaluation can be set.  Also please include any other language testing, copies of current IEPs, or pertinent information.)
• If you want to be seen for a voice or hearing appointment, then the correct supplement should be completed.
  • Hearing
  • Voice
• Consent authorization packet (Three forms should be completed; use the appropriate Consent for Services form depending on the age of the client.)
  • Release of information
  • Consent for Services - Child Version
  • Consent for Services - Adult Version
  • HIPAA Consent
• Release of Insurance authorization form
• Financial Inquiry form 

If you are interested in having the Clinic staff file for insurance, Medicare (hearing only), or Medicaid, we will require the following:  

• A copy of the member insurance ID card.
• The client, parent or legal guardian is responsible for all outstanding balances if your claim is denied.

Please note that we must have all correct forms completed and returned to our office prior to the appointment date.  If we do not have the completed forms we will have to reschedule your appointment.   Thank you for your cooperation.

 

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