if you want to save time

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 Form, a HIPAA and Consent without Doctor Referral Form, Informed Consent for Physical Therapy Treatment and Care Form, and a Credit Card Authorization Form (see links below to download pdf’s). Your credit card will be held on file and will not be used unless you miss your appointment or cancel your scheduled appointment with less than 24 hours notice. Please bring this form of payment to your appointment if you plan to pay for your visit by credit card.

  • A prescription from your physician or specialist (can be from MD, DO, Dentist, Nurse, or Midwife). It is required by the state of TN and NY that physical therapists have a prescription for physical therapy for all patients within the first month of treatment. Also, many insurance companies require a prescription for physical therapy and will not reimburse without one. Please call your insurance company to enquire.

  • Copies of relevant medical records/lab results. You may arrange to have these emailed to admin@stevekravitz.com, faxed to (646) 537-1748, or mailed to the office address from other doctors in advance.

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.  The most important field to make sure you get reimbursed directly is field #27 that says "Accept Assignment."  You must check "NO" in this field for reimbursement to come directly to you instead of your provider.

What to Mail to your Insurance Carrier for Reimbursement:

Please call your insurance company to find out the correct procedure for submitting your claim.  Some insurance companies have their own unique form that you must submit along with the HCFA form.

  • A copy of the HCFA completed with all of your pertinent information.

  • Please keep a copy of all records sent to your insurance carrier.