Referrals

How to Make a Referral/Appointment

Provider

A provider may refer a client for services by calling or faxing the clients information.

• Calling 434-395-2972
• Faxing 434-395-2622

What we need:

• Services needed/requested
  • Speech-language evaluation
  • Hearing evaluation
  • ADOS testing
• Client’s demographic information
  • Name of the responsible party (if different from the client)
  • Name of referring physician/provider
• Primary insurance information
  • Name
  • Number
• Secondary insurance information
  • Name
  • Number

Self

You may call our office at 434-395-2972 or walk into our clinic and provide this information. Any of this information may be faxed to 434-395-2622.

Most of the services we provide require a written order/referral from the client's primary care provider

We will need:

Basic Client Information

• Name
• Date of Birth
• Gender
• Physical Address (Street Number and Name, City/County, State, zip code)
• Mailing Address (if different from physical address)
• Phone Number
• Emergency contact information (Name, relationship to you i.e. spouse, mother, father, friend.
• Primary/Family doctor
• Referring doctor name 
• Primary and secondary insurance provider (s)

Client Health Information

• Allergies (food, medicine, latex)
• Major medical history i.e. surgeries, therapies

Forms

You may print and bring your completed registration form packet on the day of your appointment if you choose.

There are 3 different types of form packets:

• Audiology Adult
• Audiology Child
• Speech-language

Please call our office if you are unsure of which form packet to complete for your appointment.