Intake Paperwork - FORM 1
Policies & Procedures, Authorizations, HIPAA
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There are 2 sets of intake paperwork that must be completed and returned to us by the patient's first appointment. Please choose an option below for FORM 1 (required).

OPTION 1: Online - Click HERE to complete and submit it online. You'll be providing electronic signatures with this option.

OPTION 2: E-mail/Fax -
Click HERE  or click the DOWNLOAD button above to save it as a PDF. You may type your responses and print it out to sign OR you may print it out first, handwrite your responses and sign it. You may email the completed form to us at records@secure.dietrichspeech.com or fax it to us 855-279-3149.

OPTION 3: Mail/In-Person - Click HERE
 or click the DOWNLOAD button above to save as a PDF. Return your completed (either typed or handwritten) by mail to:  DSLS, 3579 Franklin Tower Drive, Mount Pleasant, SC 29466 OR in person to your speech-language pathologist. 
 
Intake Paperwork - FORM 2
Billing & Patient Case History
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There are 2 sets of intake paperwork that must be completed and returned to us by the patient's first appointment. Please choose an option below for FORM 2 (required).

OPTION 2: E-mail/Fax 
Click HERE  or click the DOWNLOAD button above to save it as a PDF. You may type your responses and print it out to sign OR you may print it out first, handwrite your responses and sign it. You may email the completed form to us at records@secure.dietrichspeech.com or fax it to us 855-279-3149.

OPTION 3: Mail/In-Person - Click HERE 
or click the DOWNLOAD button above to save as a PDF. Return your completed (either typed or handwritten) by mail to:  DSLS, 3579 Franklin Tower Drive, Mount Pleasant, SC 29466 OR in person to your speech-language pathologist. 
 
Intake Paperwork - FORM 3
Consent to Release Information
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This form can be completed at the beginning of services or as needed. Please choose an option below for FORM 3 of 3. NOTE: This "Consent to Release Information" form will need to be completed for each provider that DSLS corresponds with about a patient. Example: Complete 1 for the patient's doctor, 1 for his/her teacher or babysitter, 1 for his Early Interventionist (EI), etc.

OPTION 1: Online - 
Click HERE to complete and submit it online. You'll be providing electronic signatures with this option.

OPTION 2: E-mail/Fax 
Click HERE  or click the DOWNLOAD button above to save it as a PDF. You may type your responses and print it out to sign OR you may print it out first, handwrite your responses and sign it. You may email the completed form to us at records@secure.dietrichspeech.com or fax it to us 855-279-3149.

OPTION 3: Mail/In-Person - Click HERE or click the DOWNLOAD button above to save as a PDF. Return your completed (either typed or handwritten) by mail to:  DSLS, 3579 Franklin Tower Drive, Mount Pleasant, SC 29466 OR in person to your speech-language pathologist.