Check My Benefits

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
Prospective Patient Name: *

First NameLast Name
Date of Birth *

MonthDayYear
Address Where Therapy Is To Take Place:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Primary Care/ Referring Physician*
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?
Interested in:

Physical TherapyOccupational TherapyPersonal Training (Wellness)
If you have a referral or any additional information feel free to attach here. All information is protected and encrypted.

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This is a HIPPA compliant platform