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Check My Benefits
Harry Physical Therapy & Wellness
This is a HIPPA compliant platform
Please fill out the following information and our office will call you back to inform you of your financial responsibility for therapy services
How would you like to get started?
*
Private Pay (Recommended – fastest scheduling, no delays)
Use Insurance (verification required, may delay care)
Prospective Patient Name:
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Address Where Therapy Is To Take Place:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
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Area Code
Phone Number
"By checking this box, I consent to receive SMS messages from Harry Physical Therapy & Wellness related to appointment reminders or confirmation of benefits at the phone number provided above. The SMS frequency may vary. Data rates may apply. For assistance, reply HELP. Reply STOP to opt out of receiving text messages. Please review our Privacy Policy and Terms & Conditions.”
Yes
Email
example@example.com
Primary Care/ Referring Physician
If you’d like us to verify your insurance benefits, please complete the insurance section below. Keep in mind that coverage is not guaranteed and may take additional time. For quicker access to care, consider our private pay options.
Primary Insurance Name
Insurance Information (i.e. Group#, Member ID#)
Phone number for Provider (this is usually on the back of the card)
Supplemental Insurance (if Applicable):
Supplemental Insurance Information (i.e. Group#, Member ID#)
What is your chief complaint?
If you have a referral or any additional information feel free to attach here. All information is protected and encrypted.
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