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

First Last

Date of Birth*

Phone*

Email*

Insurance ID*

Insurance Group Number (if present)

Insurance Company*

Insurance Plan Name (please be specific)

Insurance Company Phone Number*

Usually on the back of the card

Patient's Address

(you can ignore this if you've already filled out a demographic form)

Street Address City State / Province / Region ZIP / Postal Code

Are you the primary card holder?*

Yes

Other Primary Card Holder

Primary Card Holder's Name

Primary Card Holder's Date of Birth

Insurance ID

Is the Primary Card Holder's Address different than the patients?*

Yes

Primary Card Holder's Address

Street Address City State / Province / Region ZIP / Postal Code

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