New Patient Forms

I will have these for you when we meet at the office, but if you want to save time, please come prepared with the following:

  • A completed Patient Info Sheet and HIPAA form (see links below to download pdf’s).
  • A prescription from your physician or specialist (can be from MD, DO, Dentist, Nurse, or Midwife).  It is required by the state of NY that physical therapists have a prescription for physical therapy for all patients.  Also, many insurance companies require a prescription for physical therapy and will not reimburse without one.
  • Copies of relevant medical records/lab results. You may arrange to have these faxed to (646) 537-1748 or mailed to the office address from other doctors in advance.

Links to download pdf’s:

Sample Completed and Blank HCFA Forms (Health Insurance Claim Form): 

See the file below for a HCFA form that is completed with a sample patient’s info (Sample Patient HCFA) and a few instructions. These claim forms will need to be filled out exactly as shown with all fields completed or insurance reimbursement may be delayed by your carrier. There is also a blank version of the HCFA form (Blank HCFA) so you can download it and fill in your information for submitting claims.

What to Mail to your Insurance Carrie
r for Reimbursement:

  • the white copy of the receipts given to you at my office (and tear off the yellow copy for your records)
  • a copy of the HCFA completed with all of your pertinent information.
  • Please keep a copy of all records sent to your insurance carrier.