Download The Charity League Hearing and Speech Center for Children

Office Use Only:
MR identification label
The Charity League Hearing and Speech Center
Referral for Hearing and/or Speech Evaluation
Appointments: Call (205) 638-7527
Physician Office Instructions: This form must be faxed to Julie Beals at (205)638-6740 prior to the
patient’s appointment.
Patient Name: _________________________________________________________ Birthdate: _______________________________
Parent(s) : ____________________________________________________________ Phone: _________________________________
Patient Appointment Date: ______________________________________________ Appointment Time: _______________________
Appointment Location: (please check one)
Children’s Hospital (Clinic 2)
1600 7th Avenue South
Birmingham, AL 35233
Phone (205) 638-9149
Children’s South
1940 Elmer J. Bissell Road
Birmingham, AL 35243
Phone (205) 638-9149
Children’s on 3rd Outpatient Center
1208 3rd Avenue South
Birmingham, AL 35233
Phone (205) 638-7500
Referring Physician: (please print) __________________________________________________________________________________
Referring Physician Address: _______________________________________________ Office Phone:___________________________
________________________________________________FAX:__________________________________
Please note: Reason for referral, diagnosis and physician’s signature are required from the physician’s office prior to the patient
being seen in the Hearing and Speech Center.
Patient referred for:
hearing test
speech evaluation (only performed at Children’s on 3rd)
Reason(s) for referral:
failed hearing test in office/at school
delayed speech/language milestones
(check any and all that apply)
failed newborn hearing screen
speech difficult to understand
parental concern of hearing loss
swallowing/feeding difficulty
teacher/school concern of hearing loss
abnormal resonance or voice
recurrent and/or chronic ear infections
modified barium swallow
developmental delay
Passy-Muir speaking valve
disease/syndrome (list)___________________________________________________________
other (list)______________________________________________________________________
Diagnosis (please list ICD-9 code): _______________________________________________________
Current Medications (list): ______________________________________________________________ MRSA Positive?
yes
no
Type of Insurance:________________________________________________
Insurance authorization number:____________________________________
Physician signature:_________________________________________________________ Date:_______________________________
Rev 08/12