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Boston Children’s Waltham
Jay S. Fishman ALS Augmentative Communication Program
Otolaryngology and Center for Communication Enhancement
Second Floor West

9 Hope Ave.
Waltham, MA 02453

* — Free parking with abundant accessible parking

For health care professionals

Physician/provider order form for Speech-Language Pathology (SLP) services

Thank you for entrusting Boston Children’s Hospital to partner with you on your patient’s care. The Center for Communication Enhancement offers the following programs with Speech Language Pathology Services:

If you are a physician, physician assistant, or nurse practitioner with a patient who requires non-urgent Speech Language Pathology services in one of the Center for Communication Enhancement programs listed above, please complete, print, and fax the form below to 617-730-6213. The Center for Communication Enhancement will contact the family within five business days to schedule an appointment or begin a scheduling intake process, when applicable, and close the loop with your practice.

This form is required to be completed for each new patient referral and for re-evaluation referral requests after 60 days from the original request. This form does not replace and is not an insurance referral request form, which is a separate document. If you have any further questions regarding this new process, please call 781-216-2200.

For more information

For more information about the Jay S. Fishman ALS Augmentative Communication Program, please contact John M. Costello, MA, CCC-SLP, director, Augmentative Communication Program, at 718-216-2220 or email