DIANE HANSEN, MA, CCC-SLP AND ASSOCIATES


1760 E River Road Suite 115, Tucson AZ 85718

phone 520.721.4544  /  fax 520.829.7743

office@speechcenteraz.com

www.facebook.com/speechcenterofsoaz/

REQUIRED FORMS

It is easy to contact your speech-language pathologist. Our telephone, fax and address are listed above. Please leave a phone number where you can be reached during our office hours. To schedule or cancel a therapy or follow-up appointment  please call within office hours or leave a message and we will get back to you.  We do our best to arrange appointments to fit with your schedule.  If you need to cancel an appointment please do so with 24 hours to avoid a fee and allow us to reschedule our time.

Please print and fill out these forms in advance! Bring records from you doctors. Your specialist looks closely at this information to gain an accurate picture of your child's development and present needs. You must have your insurance card and doctor referral or insurance authorization when you arrive.  

 

Acknowledgement of Recipt of Privacy Notice

Privacy Notice (do not need to print)

Child Information and History

Patient Registration

*PLEASE NOTE:

Your insurance may not cover speech therapy do to your contract with your insurance company. Charges for speech therapy will be applied to you deductible even if speech therapy is covered by your plan. TO avoid accruing charges please contact your insurance company to make sure the services needed are covered. If your insurance dose not cover speech therapy treatments your will be responsible for all accrued charges. 

 

 

Early Intervention

Does my child need Speech Therapy?

© 2018 Speech Center of Southern Arizona