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Speech Therapy Treatment Plan Date of this Request// Landmark Healthcare Inc. Please check type of care FAX 888 565-4225 Initial care INSURED Patient Last Name Patient First Name M. Primary 2. Secondary 3. Additional Treatment Plan MM/DD/YYYY From // To Functional decline/improvement in ADLs // Attention/orientation Initiation/follow-through Problem solving/judgment Sequencing/organization Following directions Phone Fax Previous Speech Therapy History No. of Visits Requested Additional...

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