All information submitted on this form is encrypted, transmited over a secure connection and stored on a HIPAA-compliant server.
Pediatrician/Physician Who Refered You:
List siblings and ages below:
By selecting "Text Message" or "Email" above, you hereby authorize Sprout Therapy Services LLC to send you appointment reminder via e-mail or text messages. I am aware that email reminders may contain patient or clinic information such as, but not limited to, patient first name and therapy location.
In order for us to verify coverage, we need some information from the patient's health insurance card. Choose an option below to get that information to us:
Upload a copy of your child's insurance card. Include FRONT and BACK. If needed, you can add more than one file.
Thank you for choosing us as one of your therapy providers. We are committed to providing you with quality and affordable therapy. Please read through this policy, direct any questions to us, and sign in the space provided. A copy will be provided to you upon request. We accept cash, personal checks and credit/debit cards as payment. There will be a $25.00 charge for returned checks.
Non-insurance cash pay. We welcome cash-pay patients. Please be aware that payment is expected for all services in full at the time of the visit or by the payment date listed on the invoice.
Proof of insurance. We must obtain a copy of the patient’s or their legal guardian's current and valid government-issued I.D. and insurance card. The patient must be insured under this insurance.
Verifying your insurance benefits. If Sprout is an in-network provider of your insurnace company, or Medicaid, we will contacting your insurance company to verify what services are covered under your plan. Please be aware, even if you are insured by a plan we participate with:
We want to provide the best possible services to all our clients and will work hard to schedule appointments that meet your needs. Regular attendance is important to success. We ask that you follow the attendance policies outlined below:
I have read and understand the attendance policy and agree to abide by its guidelines:
Completion of this form will serve as written permission for Sprout Therapy Services, LLC to communicate with the individuals you have listed below for the purposes you identify.
I authorize Sprout Therapy Services, LLC to send/disclose information to and receive Information from:
I understand that:
We value your privacy and abide by all HIPAA regulations. Click below to view and, or download Sprout's privacy practices.
Sprout Therapy Services, LLC occasionally takes photos or short videos for treatment and assessment purposes. Sprout Therapy Services, LLC also has a web site that is used for promotion and education. Below is permission or a decline for Sprout Therapy Services, LLC to use these photos/videos for educational purposes and legal promotion of the clinic.