Send us your Prescription and Insurance Cards:
We require an image of your Insurance Card and your Prescription/Referral (if applicable) no less than 48 hours prior to your Evaluation. Upload those documents to us now using this form. If you are unable to at the moment, there are a couple acceptable alternate arrangements for these documents. Select the one that works best for you.
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First Name
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Prescription
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Do You Have a Prescription or Referral?
Yes, I have a prescription or referral.
No, I will be using Direct Access.
If you are not able to upload these documents right now, Please select one of these options.
I will TEXT an image of my Prescription and Insurance Card to 315-635-5000 immediately or no less than 48 hours prior to my Evaluation.
I will FAX or have these documents faxed to your office immediately or no less than 48 hours prior to my Evaluation.
I will contact your office at 315-635-5000 to discuss a different acceptable arrangement for these documents.
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