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Forms, Payments, & Estimates

Forms

Thank you for choosing Connect the Tots!  Before your appointment, please print and complete the forms below:

Speech Therapy Forms

  • Patient Information Sheet

  • HIPPA Notice

  • Consent For Mutual Exchange Of Information

  • Notice Of Privacy Practice

Case History

Patient Rights & Consent

Payment Agreement

Request For Transmission Of Protected Health Information by Non-Secure Means

Electronic Payment Communications Disclosure

Surprise Balance Billing Disclosure Form

Payments

We accept cash, check, credit, and HSA.  We are a Colorado Medicaid provider and an "out of network" provider for most insurance companies (please see payment agreement form for details).  In addition to these payment methods, there are many grants and programs you can apply for to receive financial assistance for speech therapy.  If you would like additional information, please contact us.

Estimates

As a self-pay patient, you are entitled to, and will be provided with, a good faith estimate which outlines the potential costs associated with your evaluation and treatment in our office.  The good faith estimate is based on a suggested treatment plan for you.  This treatment plan may change during our time together and you are entitled to an updated estimate at any time.

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