Online Payment

Complete this short form and we will give you a call within one business day to set up an appoitment/evaulation and gather any other information we need.

All information submitted on this form is transmited over a secure connection and stored on a HIPAA-compliant server.

Person Filling Out Form *

First Name Last Name

Patient's Name *

First Name Last Name

Email Address *

Phone Number *

- Area Code Phone Number

Good Time to Call *

Mornings Afternoons Either

Briefly explain your concerns/needs *

Will you be using health insurance or medicaid? *

Yes, if possible No

Select the patient's health insurance. Listed are the insurers we are in network with.

Do you have a referral for therapy from a doctor?

Yes, and it is made out to Sprout Therapy Services Yes, but it is NOT made out the Sprout Therapy Services No

A doctor's referral is required for us to submit to your insurance. Contact the patient's primary doctor and have them send us a referal for speech therapy. Our fax number is 719-452-3520.

A Tricare Authorization is required for us to submit to Tricare. Contact the patient's primary doctor and have them enter a Tricare authorization for speech therapy with Sprout Therapy Services as the provider. If you have any questions about this, give us a call.

Does the patient have secondary insurance or medicaid?

Yes No

Select the patient's second health insurance.

Appointment Request