Payment Form

"Please upload your EOB; include all pages. If submitting for multiple dates of service, you can upload up to four individual files(example PDF's) per submission"
Did an insurance payment come directly to you with your EOB? (Explanation of Benefits)

YesNo
Please upload your EOB; include all pages
Do you have more than one EOB form? Upload it here.
If you have additional EOB's Upload them here.
If you have additional EOB's Upload them here.
Patient First Name
Patient Last Name
"What payment amount came with your EOB?(If from multiple EOB's please pay one total amount with this submission)"

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USDPayment for Sprout Services
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