Requirements for New Individuals to the IPSIDD/INDEPENDENT Program

Requirements for New Individuals to the IPSIDD/INDEPENDENT Program:

Fill out the form carefully for registration
Multi Practitioner’s Group statement:

We would appreciate the prompt completion of this packet. Please fax or mail items immediately to the assigned Intake Coordinator.

Name of Groups:

● Keep Talking Speech Language Services, PLLC [KPT]
● NP Family Health Visits & NP Adult Health Visits, PLLC [NPV]

Attn: Yvonne Pasqualicchio, Program Development
Address: 2269 Lyell Avenue Suite 103
Address: Rochester NY 14606
Phone: 845-800-9305
Fax: 844-800-1470
Email: yvonnep@selectmulticare.com
E-mail*
example@example.com
IPSIDD/INDEPENDENT SERVICES REFERRAL FACE SHEET Revised 05.01.2024 KPT
Name*

Last NameFirst Name
DOB:*

MonthDayYear
SSN:*
Medicaid #*
Medicare # (optional)*
Other Ins. (send copy of front and back of card)*
Full address of Treatment Location. (Specify: Group Home, Private Home, Day Hab, Other)*
Treatment Location Contact’s Name/ Relationship*
Contact’s Best Phone #*
Contact’s Email*
Name, Email, Phone of Care Manager.(Specify which CCO)*
Name of Individual or Representative*
Please upload your Life Plan (most recent existing on file.)

Before uploading document please read requirement's below
Cancelof
Requirements:

● If Medicaid or Medicare, only provide the Medicaid number. That’s all we need. We run an ePaces MEVS check!
● If duals advantage or BCBS, or Fidelis, etc. then we will need front and back of current card(s)
● Scripts: Optional, not mandatory to initiate speech & language services
● Ongoing Scripts: provided by the NPV group. No long wait!
Referred to IPSIDD program for:

ST Speech Therapy: Ameliorate effects of expressive and receptive language disorders, swallowing disorders, sign language to indicate needs and wants
CONSENT/RELEASE STATEMENT

I am consenting to receive IPSIDD/Independent clinical services from the above Multi Practitioner Groups. I authorize any holder of medical information about me to release to the Group’s Claims Administrators any information needed to determine these benefits or the benefits payable for related services.

NOTE: Individual is unable to sign. Responsible party is completing the below on individual’s behalf
Name of Individual or Representative **
Title/Relationship to individual*
Type a question

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Signature*
Date of consent *
Intake. Keep Talking Speech & Language Services, PLLC
President & CEO: Pamela Green. MS/CCC-SLP
Should be Empty:

Requirements for New Individuals to the IPSIDD/INDEPENDENT Program: