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Patient Forms for WellNow Urgent Care, P.C.

W-9 Forms for MI, OH and IN

Medical Insurance W-9

(This will be used for Worker’s Compensation Carriers and Medical Insurances purposes for patients treated at any of our Michigan, Ohio, Indiana Wellnow Locations.)


Occupational Medicine Employer W-9

(This will be used for any Companies whose Employees received Occupational Medicine services at any of our Michigan, Ohio, Indiana Wellnow Locations.)

W-9 Forms for NY and IL

Medical Insurance W-9

(This will be used for any Worker’s Compensation Carriers and Medical Insurance purposes for patients treated at any of our New York and Illinois Locations.)


Occupational Medicine Employer W-9

(This will be used for any Companies whose Employees received Occupational Medicine services at any of our New York and Illinois Wellnow Locations.)

No-fault Insurance for NY patients

New York is a no-fault insurance state and patients must sign a no-fault form to assign benefits to the provider.

dba WellNow Urgent Care

P.O. BOX 1848

Albany, NY 12201-1848

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Amelia
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