Provider Forms

Below please find some forms that may be useful to your facility or your providers. Please feel free to contact us if you have any questions or need anything else!

1. FEES Informed Consent Form

This form should be filled out before we are able to come out and perform FEES.

2. Videostroboscopy INFORMED CONSENT FORM

This form should be filled out before we are able to come out and perform Videostroboscopy.

3. Professional Liability/MALPRACTICE Insurance PROOF OF COVERAGE

This is a copy of our current Professional Liability Insurance Certification, showing our $2,000,000 (individual) / $5,000,000 (aggregate) insurance coverage.

4. Department of Health/Medical Quality Assurance License & ASHA CCC-SLP

This is a copy of our current state DoH/Medical Quality Assurance license, as well as our current ASHA CCC-SLP.