Reduced Fee Treatment Application 

To begin the referral process, please download and submit the application.

Download the application: 
Application (.doc - fill out electronically)

Application (.pdf - print and fill out by hand)

How to submit your application and fee:

Email or Fax:

PANY abides by HIPAA privacy guidelines, which means that after we receive your application, we will treat it with the utmost care in order to respect your privacy. As an applicant to our Consultation and Treatment Services, you may email your application to our office, with the understanding that email is not a private or secure system.

- Please note that during the COVID-19 pandemic we are unable to accept applications by postal mail. 

• Email application to This email address is being protected from spambots. You need JavaScript enabled to view it. or fax your application to our confidential, private fax line at 646-754-9540.

Application fee payment:

• Using Paypal (click on "Pay Now" link):

Treatment Application Fee

Option 1 $50.00 USD

• or Send payment electronically using Zelle to This email address is being protected from spambots. You need JavaScript enabled to view it..

If you do not receive a phone call or email that we have received your application within 2 weeks of submission, please contact the PANY office at 646-754-4870.

Thank you.