Name *
Name
Phone Number *
Phone Number
Date of Birth *
Date of Birth
Address
Address
Insurance Phone Number
Insurance Phone Number
Found on back of card
Name of Insured (if other than yourself)
Name of Insured (if other than yourself)
Date of Birth of Insured
Date of Birth of Insured
Name *
Name
By typing your name you attest that you are the person filling out this form and this acts as your signature
Assignment of Benefits *
I hereby assign all rights, privileges and remedies to payment for health care services to Tyner Physical Therapy. I also authorize Meg Tyner PT, DPT, ATC, CSCS having treated me, to release to government agencies, insurance carriers and all others who are financially liable for my care, all information needed to substantiate payments for care and to permit representatives thereof to examine and make copies of all records relating to such care and treatment. I have read and understand the privacy practices of the office.
Notice Of Privacy Acts *
Checking this box below indicates that you have received a copy of Tyner Physical Therapy’s Notice of Privacy Practices on the date indicated.
Billing and Cancellation policies *
Checking the box below indicates that you agree to the terms: • Payment of all co pays is expected at the time of service or at the end of the week if you come for multiple treatments per week. • Fee for service is $125. In the event that your insurance does not cover this fee the responsible financial dependent will be responsible to cover the FULL fee for service. • A scheduled appointment must be cancelled at least 24 hours in advance or a $75 cancellation fee will be assessed. Similarly, if you do not show up for an appointment the $75 cancellation fee will also apply. The fee is not waived for business or travel and is not billable to any insurance carrier.

No referral or prescriptions needed here!

All you need to do is make an appointment and walk in the door to begin the the path towards improving your health – we’ll handle the rest.  We will work with most major insurances out of network and submit the claims on your behalf so you can spend your time getting better, not on paperwork.  The most common plans include:

  • Aetna PPO & POS

  • Cigna PPO & POS

  • BCBS PPO & POS

  • United Healthcare PPO

For patients without out of network benefits, sessions are available in affordable payment plans. Getting your body to feel better is not only important physically, but it’s vital to keeping a mental balance. One visit with us and you’ll feel the difference between us and those insurance-based clinics.

Hours

Monday: 7AM-7PM

Tuesday: 7AM-7PM

Wednesday: 7AM-12PM

Thursday: 7AM-7PM

Friday: 7AM-10AM

 

Tyner Physical Therapy, PLLC. 5 Harrison St. NY, NY 10013. TynerPT@gmail.com. 212-281-6412

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