Please read through and complete all of the documents below to the best of your ability. In addition, we request the following:
- A copy of insurance card (front and back)
- Any pertinent medical records
- A copy of a valid photo ID (e.g. driver’s license, passport, etc.)
Patient-Healthcare Provider Electronic Communication Agreement_
Medical Release Form – New York
Patient Credit Card Patient Form
Medical Coverage Questionnaire
New Patient Questionnaire NY
Notice of Privacy Practices
Please send all documents to SIRMNYPatientServices@sherinstitute.com or fax them to (212) 689-1116. As a reminder, we require your insurance information 72 hours prior to your appointment to ensure your visit will be covered. If you do not send us your information, your insurance provider might not pay for the visit. In this case, you would be responsible for the $450 New Patient Visit fee. If payment is received from your insurance at a later date, you will receive a refund.
Please be advised that any costs for the consultation and services rendered are the responsibility of the patient at the time of the visit.