All Medicare Supplemental Plans
Empire Blue Cross Blue Shield (all states)
United Healthcare
The Empire Plan
1199 SEIU

Any insurance with out of network benefits

If you are coming for a NECK injury, please fill out the

If you are coming for a BACK injury, please fill out the

If you are coming for an UPPER EXTREMITY injury, please fill out the

If you are coming for a LOWER EXTREMITY injury, please full out the


* Based on your insurance, there may be additional forms to fill out the day of your initial visit.


In New York State, patients are able to be evaluated and treated by a licensed physical therapist without a physician’s referral, called Direct Access. Some insurance plans may still require you to obtain a prescription from your physician first, so please check with your insurance provider.  

New York Direct Access provisions are as follows:

  • Treatment can be rendered by a Licensed Physical Therapist for 10 visits or 30 days, which ever comes first.
  • You must sign a written notification which states that services without a referral might not be covered by your health plan or insurer.


For more information on this matter, visit

You may be responsible for a co-pay, deductible, or co-insurance.  We would be more than happy to call your insurance and find out what your patient responsiblity will be.  Leave us your name, insurance ID, and date of birth and we will contact you with the information.