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Dr. Kant LogoDr. Kant Logo
  • Home
  • Services
    • General Adult Psychiatric Services
    • Child and Adolescent Psychiatry
  • About
  • Forms & Links
    • New Patients
    • Office Forms
    • Medications / Refill Request
    • Links & Info
  • Telehealth
  • Contact Us

Advance Beneficiary Notice

Advance Beneficiary NoticeNPCAnna2023-08-20T23:33:56-04:00

Advance Beneficiary Notice

MM slash DD slash YYYY
Patient Name*
MM slash DD slash YYYY
Responsible Party*
If patient is a minor or has a legal representative or guardian, additional information is needed.
Responsible Party*

If the insurance plan does not pay for the medical services listed below, or we do not participate in your insurance plan, you will be required to pay out of pocket. The insurance plans do not pay for everything, even some care that you or your health care provider have good reason to think you need.

Service(s)/Reason(s):*

Reason the Insurance Plan May Not Pay: Non-covered service or Not in network provider

Estimated cost: $85-$250 depending on treatment. Cost may vary depending on the service/s

WHAT YOU NEED TO DO NOW:

Read this notice, so you can make an informed decision about your care. Please feel free to ask any questions that you may have after you finish reading this form. Choose the preferred option below.

Choose an Option*

This notice is not an official insurance plan decision. If you have other questions on this notice regarding insurance billing, please call your insurance company. Signing below means that you have received and understand this notice. You may also receive a copy.

I certify that this data is true, correct & accurate. I understand that payment of this claim will be from federal & state funds. Any false claims, documents, or concealment of material facts may be prosecuted under applicable laws. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.

Clear Signature
Clear Signature
MM slash DD slash YYYY
New Patients: Request Initial Appointment
Existing Patients: Update Your Information
Pay Your Balance

Your account number can be found on your mailed statement.

COVID-19 Information

Medication Refills

We have transitioned to a new Electronic Health Record (EHR), Valant.

MYIO portal invitations have been sent out to patients. Please use the link and your access code sent to your cell phone or email to create your account.

Please download the app to your phone or login from a computer using this link: https://valant.io/myio/RaviKantMDPC

After July 31, 2024, ALL telehealth and patient-provider/office communication will be done through your MYIO patient portal. You will no longer be able to request med refills or send your provider messages through our website.

If you have any questions regarding your MYIO patient portal, please contact our office.

Medication Refills

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© 2025 NeuroPsychiatry Center. All Rights Reserved. • 300 Old Pond Road, Suite 201 • Bridgeville, PA 15017 • (412) 220-7323 • Fax: 412-220-7325

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