Feeding the Body. Feeding the Mind.

OUR FORMS

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Pediatric Feeding & Speech Solutions, PLLC is an in-network provider for a number of insurance companies.  

Please inquire about insurance participation when making an appointment.  

For Any Service:
Feeding, Speech and Language Therapy or Orofacial Myofunctional Disorders

  1. Please request an “order” or “prescription” from your child’s ordering physician stating either “feeding evaluation and therapy,” or “speech and language evaluation and therapy,” or “orofacial myology evaluation and therapy.”
  2. Bring the order with you or have the doctor’s office fax the order directly to 703-771-7080.
  3. Call your insurance company and ask about your “speech therapy” benefits, co-pays, deductibles, exclusions, visit limitations, etc.
  4. We DO NOT CALL your insurance company in advance. YOU are responsible for obtaining a referral if needed, knowing your visit limitations and letting us know if a pre-authorization is required by your insurance.
  5. Bring all forms, your insurance card and ID to the evaluation.

Please download, print, fill out and bring all applicable forms with you to the evaluation.

Feeding Evaluation

  1. Please request an "order" or "prescription" from your child's pediatrician stating "feeding evaluation and therapy" You can bring this with you or have the doctor's office fax it directly to 703-771-7080.
  2. Call your insurance company and ask about your “speech therapy” benefits, co-pays, deductibles, exclusions, visit limitations, etc.
  3. We DO NOT CALL your insurance company in advance, you are responsible for obtaining any referral that is required by your insurance 
  4. Bring all forms, your insurance card and ID to the evaluation.
  5. Please bring a few preferred or easy foods and a few non-preferred or more difficult foods/ liquids for your child.  Please bring any special nipples, bottles, spoon, or cups.


    Please download these forms, print, fill out and bring with you to
    the evaluation.

     

Speech/Language Evaluation

  1. Please request an "order" or "prescription" from your child's pediatrician stating "speech and language evaluation and therapy" or another appropriate description. Bring the order with you or have the doctor's office fax it directly to 703-771-7080. 
  2. Call your insurance company and ask about your “speech therapy” benefits, co-pays, deductibles, exclusions, visit limitations, etc.
  3. We DO NOT CALL your insurance company in advance, you are responsible for obtaining any referral that is required by your insurance 
  4. Bring all forms, your insurance card and ID to the evaluation.


    Please download these forms, print, fill out and bring with you to the evaluation.

Orofacial Myofunctional Disorders

  1. Please request an "order" from your/your child's doctor, dentist or orthodontist stating "OMD evaluation and therapy" or another appropriate description. Bring the order with you or have the doctor's office fax it directly to 703-771-7080. 
  2. Call your insurance company and ask about your “speech therapy” benefits, co-pays, deductibles, exclusions, visit limitations, etc.
  3. We DO NOT CALL your insurance company in advance, you are responsible for obtaining any referral that is required by your insurance 
    Bring your insurance card to the evaluation
  4. Bring all forms, your insurance card and ID to the evaluation.


Please download these forms, print, fill out and bring with you.