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