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Register with SproutWell

Welcome to the SproutWell registration page. To register as a new patient, please enter your information in the fields below. Please do not use this form if you are already a patient (you have seen any of our practitioners in the past). To set up patient portal access or amend your information, please contact us.

If you are already a registered patient with online access, you can log in here

Patient Information

Patient is a minor Patient is an unborn child

First Name * Middle Name (or initial) Last Name * Date of Birth * Nickname/Preferred Name Gender * Race Ethnicity

Parent Information

First Name * Middle Name (or initial) Last Name * Date of Birth * Sex * Nickname/Preferred Name Mobile Phone Number * Home Phone Number Work Phone Number Preferred Contact Number Email Address

Contact Information

Mobile Phone Number Home Phone Number Work Phone Number Preferred Contact Number Email Address (Primary) * Secondary Email Address

Home Address

Address 1 * Address 2 City * State * ZIP Code *

Emergency Contact

First Name * Middle Name Last Name * Relationship to Patient Email Address Phone Number *

Insurance Information

Note: Our practice does not bill insurance, but this information makes it easier for us to refer you for other services (like labs or specialists)

Plan Name Group Number Member ID Insurance Type

Medical Information

Please enter your basic medical information below. You may also add or edit this information after you've signed up.

Height (in INCHES) Weight (in POUNDS) Personal Medical History (please also include surgeries and hospitalizations) Relevant Family Medical History (indicate which family member if applicable)

Set Username and Password for Patient Portal

Please create a username and password that you will use to log into the patient portal in the future.

Your username must be at least 4 characters long.
Each registering family member must have a unique username and password.

Username *

Your password must be at least 8 characters long and include at least one number or special character.

Password * Confirm Password *

"I consent to having medical information sent to my email address (we cannot guarantee the security of messages delivered by email)." "I have read and accept the terms of the privacy policy below:" *

The Notice explains how we fulfill our commitment to respect the privacy and confidentiality of your protected health information. This Notice tells you about the ways we may use and share your protected health information, as well as the legal obligations we have regarding your protected health information. The Notice also tells you about your rights under federal and state laws. The Notice applies to all records held by SproutWell's facilities and programs, regardless of whether the record is written, computerized or in any other form. We are required by law to make sure that information that identifies you is kept private and to make this Notice available to you.

Your Rights

When it comes to your health information, you have certain rights.

This section explains your rights and some of our responsibilities to help you.

Get a copy of your paper or electronic medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Correct your paper or electronic medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we'll tell you why in writing within 60 days.
Request confidential communication
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests.
Ask us to limit the information we share
- You can ask us not to use or share certain health information for treatment, payment, or our operations.
  - We are not required to agree to your request, and we may say "no" if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
  - We will say "yes" unless a law requires us to share that information.
Get a list of those with whom we've shared your information
- You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you believe your privacy rights have been violated
- You can complain if you feel we have violated your rights by contacting us using the information in this notice.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to
  
  200 Independence Avenue, S.W.
  Washington, D.C. 20201
  by calling 1-877-696-6775, or visiting HHS.GOV Complaints .
- We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share.

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us what to share
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising
- We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you
- We can use your health information and share it with other professionals who are treating you.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
- We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
- We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: HHS.GOV consumer home .

Help with public health and safety issues
- We can share health information about you for certain situations such as:
  - Preventing disease
  - Helping with product recalls
  - Reporting adverse reactions to medications
  - Reporting suspected abuse, neglect, or domestic violence
  - Preventing or reducing a serious threat to anyone's health or safety
Do research
- We can use or share your information for health research
Comply with the law
- We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law
Respond to organ and tissue donation requests
- We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers' compensation, law enforcement, and other government requests
- We can use or share health information about you:
  - For workers' compensation claims
  - For law enforcement purposes or with a law enforcement official
  - With health oversight agencies for activities authorized by law
  - For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
- We can share health information about you in response to a court or administrative order, or in response to a subpoena

Electronic Access

We provide electronic access to your health information via the Cerbo Patient Portal.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: HHS.GOV consumer notice .

Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

This notice is effective as of 11/21/2024.

* I have read and consent to the Memorandum of Understanding below:

Memorandum of Understanding

I understand and acknowledge the following SproutWell practice guidelines:

Patient Portal: You will be asked to register through our patient portal prior to your Initial Consultation. There are important forms and intake information that Dr. Julie Sweeney needs to review prior to your first appointment. All patient related communication and lab/data sharing should be handled through the portal to allow for encryption to protect your family's privacy. Please do not email our practice with personal medical information.

Care Team/Communication: Dr. Julie is delighted to join your child's multidisciplinary care team. Each child must have a personal primary care provider for routine and sick care. Dr. Julie's review of medical records (medical history, labs, diagnosis and treatment), advice and integrative plan are based on this understanding. Our integrative-minded practice is designed to augment your child's pediatric care, not replace it. When given permission, Dr. Julie can communicate directly with your child's pediatrician, allergist, gastroenterologist and other specialists.

Insurance: We are "out of network" and do not bill insurance. Many of our patients who have out of network benefits as part of their coverage are able to be reimbursed for services by submitting a detailed invoice or "superbill" to their insurance provider. If you would like to submit our invoice for reimbursement, please let us know at the time of your appointment. We regret that we cannot engage with insurance companies to determine coverage.

Fees: By signing below you understand and agree to our office fees as posted on our website under "FAQs + Pricing". Our fees are subject to change from time to time.

Annual Membership Package: This package is available to a limited number of families. The appropriate fit for the membership package is up to the discretion of Dr. Julie Sweeney. Please see our website for more details.

See our website for more information about what is included in our fees.

Payment: You will be responsible for the full cost of your visit at the time of service. Please note that we require each family to have a valid credit card on file. This can be a flexible spending or health savings account (FSA/HSA) debit card. Please let us know if your card on file needs to be changed for any reason.

Cancellation Policy: Dr. Julie reserves your full appointment time exclusively for you. If you need to cancel or reschedule, please do so at least 48 hours prior to your appointment. A fee of $100 will be charged for changes made less than 24 hours in advance of your scheduled appointment time.

Personalized Care Plans: After the Initial Consultation your Visit Summary/Personalized Care Plan will be available through the patient portal. This plan will be updated after each follow up visit.

Multiple Children in a Family: Each child is unique and must be registered individually in the patient portal. Dr. Julie's consultations include coaching and empowering the whole family, but we ask that each appointment is primarily focused on one child at a time.

We look forward to meeting you and your child!

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Register with SproutWell

Patient Information

Parent Information

Contact Information Same as Parent

Home Address

Emergency Contact Use Parent's Info

Insurance Information

Medical Information

Set Username and Password for Patient Portal

Get a copy of your paper or electronic medical record

Correct your paper or electronic medical record

Request confidential communication

Ask us to limit the information we share

Get a list of those with whom we've shared your information

Get a copy of this privacy notice

Choose someone to act for you

File a complaint if you believe your privacy rights have been violated

In these cases, you have both the right and choice to tell us what to share

In these cases we never share your information unless you give us written permission

In the case of fundraising

Treat you

Run our organization

Bill for your services

Help with public health and safety issues

Do research

Comply with the law

Respond to organ and tissue donation requests

Work with a medical examiner or funeral director

Address workers' compensation, law enforcement, and other government requests

Respond to lawsuits and legal actions

Electronic Access

Memorandum of Understanding

Contact Information

Emergency Contact