Speech, Language, and Hearing Services Referral for 2009-2010 School Year

Student:
Date of Birth:
Attending District:
School Building:
Last IEP Date:

Date:

Dear Dr. Popper:

This student qualifies for special education services as a student with speech and language impairment in accordance with the Michigan Revised Administrative Rules for Special Education (June 6, 2006). Through formal assessment the communication disorder that adversely affects educational performance has been determined to be:

Language	Articulation	Fluency	Voice	Hearing Impairment

For school districts to bill for speech, language, and hearing services through the Medicaid School Based Fee-for-Service Program, the Michigan Department of Community Health Guidelines state that a referral must be ordered in writing by a physician. A referral means “contact by a physician with the speech pathologist or audiologist providing the services or with an enrolled School Based Services provider for Special Education and related services.”

If you agree with this referral, please sign this form and return it to the address listed above.

Sincerely,

________________________________________________	______________________

Speech and Language Pathologist/Audiologist	Date

I agree with the referral for speech, language, and hearing services for this student, inclusive of assistive technology device services as necessary. This written referral is effective for one calendar year, beginning on the first day of school, or when the child began receiving speech, language, or hearing services per the IEP, (such date being noted above), whichever occured later.

_______________________________________________	________________________

Signed by: Dr. Steven D. Popper, M.D.	Date

Monroe County Intermediate School District

1101 South Raisinville Road

Monroe MI 48161-9047

Phone: 734/242-5799 Ext. 1444 Fax: 734/242-5807

Revised 8/25/2009

Monroe County Intermediate School District

Joan A Sterns

2009-08-25

MCISD