ASSIGNMENT OF BENEFITS

I understand that my insurance company will be sent an itemized bill for each session in accordance to reasonable and customary charges. I agree to assign benefits directly to Dr. Dmitry Choklin, PT, DPT for all therapy services rendered. I also agree to remit any monies sent to me from my insurance company for services rendered to Dr. Choklin. I agree to pay for all services rendered UP to $350.00 (the out-of-pocket cost for an initial evaluation or follow-up treatment) should my insurance company deny payment for services rendered and will be responsible for any deductible or co-insurance due as per the terms of my insurance plan. (Please enter full name below)


Contact Info

Dmitry R. Choklin
PT, DPT, CSCS, CKTP

Cell: (917) 328-8098
Fax: (866) 282-1162
Email: dchoklin@yahoo.com

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Physical Therapy in NYC

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