Referral Form

Last name:

First name:

Middle name:

Diagnosis:

Diagnosis Date:

Birth Date:

Age:

Sex:
MF

Address:

City:

State:

ZIP Code:

Phone:

Alternate Phone:

Email:

Occupation:

Employer:

Employer Phone:

Reason for Referral

Physician Information

Name of Primary Care Physician:

Address:

Suite:

Phone:

City:

State:

ZIP Code:

Fax:

MD License:

NPI:

UPIN:

Insurance Information

Please note: Unified’s No Boundaries Assistive Technology Center does not accept Insurance, Medicare, or Medical Assistance as forms of payment for assessments, therapy, or training. Information below should be completed for Patients receiving a Communication Device Assessment to assist in procurement of the communication device:

Payment Information

Method of Payment for assessment/therapy/training:CashCheckCredit

Fee Schedule

Fees for services are listed below. Payment may be made on the day of service or, for your convenience, an invoice can be mailed following provision of services:
Pay on day of servicePlease invoice

Augmentative and Alternative Communication Assessment/Assistive Technology/Computer Access Assessment	$300.00 for the initial assessment appointment $100.00 per hour if a second session is warranted

Speech & Language Assessment	$300.00 for assessment

Augmentative and Alternative Communication Set-up/Therapy/Training	$125.00 per hour
Assistive Technology/Computer Access Set-up/Therapy/Training	$125.00 per hour
Speech & Language Therapy	$125.00 per hour
Presentations/Training	$125.00 per hour _{(does not include the cost of any requested presentation materials)}

Travel fees for any service occurring outside of Unified’s main office	$40.00 per hour

Interested in:Office AppointmentIn-home Appointment

Unified Community Connections
No Boundaries Assistive Technology Center

Patient Information

Reason for Referral

Physician Information

Insurance Information

Payment Information

Fee Schedule

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Referral Form

Unified Community ConnectionsNo Boundaries Assistive Technology Center

Patient Information

Reason for Referral

Physician Information

Insurance Information

Payment Information

Fee Schedule

Quick Links

Stay Connected

Contact Us

Subscribe to our newsletter

Unified Community Connections
No Boundaries Assistive Technology Center