Your Name *

First Name

Last Name

Name of Patient if Different *

First Name

Last Name

Phone *

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You have the option to use your insurance for a select number of our services. If you are scheduling an evaluation for OT, PT, or Speech, please choose how you would like us to bill for your evaluation. If your insurance provider is not listed we can not bill them directly, but can provide you with a detailed invoice if you'd like to seek reimbursement from your plan. *

Anthem BCBS

UHC or UMR

Private Pay

I'm not scheduling OT, PT or Speech and understand that pricing details will be provided to me prior to schedule.

If you are scheduling an OT or PT evaluation, we will need an order for the child's doctor. Choose one of the following. *

My doctor already sent the order.

I will request the order from my doctor ASAP and will have them fax it to 636-249-1155

I need assistance in obtaining an order.

I am not scheduling an evaluation for OT or PT

If you are scheduling an evaluation with a speech therapist (including anyone who was referred by their dentist or orthodontist) AND want us to bill your insurance we will need an order from your doctor. *

My doctor already sent the order.

I will request the order from my doctor ASAP and ask them to fax it to 636-249-1155

I am not scheduling speech therapy.

I am scheduling speech but will private pay.

Choose one of the following *

I will take a picture of the front and back of our insurance card and email it to info@showmespeech.com

I am not using my insurance plan.

Your Name *

First Name

Last Name