Branching Tree Speech Therapy, PC

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

Gender

Address:

Including the street address, city, state, and ZIP code.

Preferred Language

Allergies:

Including medications, foods, and other substances.

Administrative

Inquiry reason

Referral Source

Enter how you were referred to our services

Billing & Payment

Payment Method

How do you plan to pay?

What is the name of your insurance provider?

Insurance card upload

Upload a photo of your insurance card

What is the name of your insurance provider?

What type of plan do you have?

PPO HMO

Member ID:

Disclaimer: This information must be provided in order to verify eligibility and benefits.

Group ID:

Primary Policy Holder Information:

Disclaimer: This information is required to verify eligibility and benefits and may be requested by your insurance company for coverage determination.

Full Name:

Date of Birth:

Sex:

Phone Number:

Home Address:

Do you have any secondary insurance coverage?

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.