60 Dunning Road, Suite 1, Middletown, NY 10940-2215 (845) 344-4477

Forms

If you are a first-time patient to our practice, please read the general instructions below. Then complete the forms below that apply to you and return them via mail (US Postal), fax (845-344-6072) or email (advantagepmr@protonmail.com). 

Please bring the following with you to your appointment:

  • Your insurance cards and a referral (if required). Please check with your insurance carrier and/or PCP.
  • Prior diagnostic testing results/report (MRI, CT, X-RAY) that is relevant to your current visit/condition.  Radiology facilities may require 24-48 hrs advanced notice to process your request.
  • Any co-payment as dictated by your insurance company.

If any of the above information is missing or incomplete, your appointment will likely be delayed or even rescheduled.  We thank you for your cooperation and look forward to seeing you in our office.

Forms:

For ALL patients:

For Workers’ Compensation patients, this additional form:

For No-Fault patients, these additional forms:

Formularios en espanol

Para todas las pacientes:

Para los pacientes de compensación para trabajadores, este formulario adicional:

Para pacientes sin culpa, estos formularios adicionales:

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