(212) 366-4450
Physical Therapy Associates of New York
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Insurance Verification Form

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Insurance Verification Form

We are IN-NETWORK with the insurance companies above and are a non-participating provider for Medicare. If your insurance company is not listed above we can also review your OUT-OF-NETWORK benefits with you. Please fill out the following form and we will contact your insurance company. Once your benefits have been verified we will call you back to review your benefits and schedule an appointment. Feel free to call us at (212) 366-4450 if you have any questions.

"*" indicates required fields

PATIENT INFORMATION

Name*
must match insurance card
MM slash DD slash YYYY
Usually on the back of the card
Patient's Address
(you can ignore this if you've already filled out a demographic form)
Are you the primary card holder?*

Other Primary Card Holder

MM slash DD slash YYYY
Is the Primary Card Holder's Address different than the patients?*
Primary Card Holder's Address

HIPAA Consent
Although this form is dual encrypted using SSL & PGP, there is the slight possibility that this communication can be intercepted in transmission, decrypted, or misdirected. Your use of email to communicate protected health information to us indicates that you acknowledge and accept the possible risks associated with such communication. If you do not wish to have your information sent by email, please call us with the information at (212) 366-4450 or you can download this form and fax it to (855) 486-2314.

Office Hours
Mon, Weds
11:00AM-7:00PM
Tu, Thu, Fri
8:00AM- 4:00PM


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19 West 21st St, Suite 404

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Physical Therapy Associates of New York

19 West 21st Street, Suite 404
New York, NY 10010

212 366-4450
info@ptany.com

Our Office Hours

M,W 11:00AM-7PM
T,Th,F 8:00AM-4PM

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