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Physical & Massage Therapy

Insurance Verification Request

Now in 2 convenient locations Winter Park & Waterford Lakes

 

WINTER PARK

1860 State Rd 436. Suite 1000
Winter Park, Florida 32792
Tel: 407-657-5029
Fax: 407-657-6320

 

WATERFORD LAKES

12301 Lake Underhill Rd., Suite 118
Orlando, Florida 32828
Tel: 407-218-4660
Fax: 407-218-4661

eric@pt-works.com


Insurance Verification

In order for us to verify your insurance coverage please fill out the following form.

*Please note that all fields beginning with an asterisk must be filled in.

*First Name:
*Last Name:
*E-mail Address:
*Street Address:
*City:
*State/Prov:
*Zip/Postal Code:
*Home Phone:
Business Phone:
*Health Ins Co:
*Member ID#:
*Group#:
Customer Service Tel# (see back of card):
*Medical Diagnosis:
*Referring Doctor:
*Your Date of Birth:
 
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