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Home
Services
- General Adult Psychiatric Services
- Child and Adolescent Psychiatry
About
Forms & Links
Telehealth
Contact Us

Form For New Patients

Form For New PatientsNPCAnna2023-08-20T10:49:20-04:00

We do not accept United Behavioral Health/Optum or Health America/Coventry insurances. We apologize for any inconvenience this may cause.

Step 1 of 4

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Patient Information

Today's Date*

MM slash DD slash YYYY

Patient Name*

First Name Middle Initial Last Name

Sex*

Male

Female

Identified Gender*

Date of Birth*

MM slash DD slash YYYY

Age (ex 23)*

Marital Status*

single

married

divorced

separated

other

Person Requesting Appointment*

First Name Middle Initial Last Name

Relationship to Patient

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

County*

Allegheny

Beaver

Butler

Washington

Other

Mobile/Cell Phone*

Home Phone

Email*

Referred By:

Reason for Referral*

Current Treating Physician

Are you taking any medication currently?*

Yes

No

What medications are you taking?

Allergies*

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Emergency Contact

This field is hidden when viewing the form

Emergency Contact*

First Last

This field is hidden when viewing the form

Emergency Contact Phone*

This field is hidden when viewing the form

Emergency Contact Relationship*

This field is hidden when viewing the form

Responsible Party*

If patient is a minor or has a legal representative or guardian, additional information is needed.

Patient

Guardian or Legal Representative

Responsible Party Info

Responsible Party*

First Last

Responsible Party Address

(if different from patient)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Responsible Party Phone*

Responsible Party Email*

Insurance Information

Primary Insurance*

Primary Insurance Group Number

Primary Insurance Policyholder Name*

First Last

Primary Insurance Policyholder Relationship to Patient*

Primary Insurance Policyholder Date of Birth*

MM slash DD slash YYYY

Primary Insurance Policy Number*

Do you have another insurance policy?*

Yes

No

Secondary Insurance*

Secondary Insurance Group Number

Secondary Insurance Policyholder Name*

First Last

Secondary Insurance Policyholder Relationship to Patient*

Secondary Insurance Policyholder Date of Birth*

MM slash DD slash YYYY

Secondary Insurance Policy Number*

Workers Comp / Auto Claims

Is this a worker's compensation or auto claim?*

Yes

No

Case Manager*

Insurance Company Name*

Insurance Company Phone Number*

Claim Number*

Date of Injury*

MM slash DD slash YYYY

Comments

Would you like to sign up to receive updates and important announcements?*

Yes please!

No thanks.

All patients MUST have a credit card on file for their co-pays, deductibles, co-insurance, and other charges related to your care in order to receive services. This DOES NOT apply to medical assistance patients.

Comments

This field is for validation purposes and should be left unchanged.

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

New Patients

Office Forms

Directions

Sign up to receive updates and important announcements!

Leave this field empty if you're human:

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© 2024 NeuroPsychiatry Center. All Rights Reserved. • 300 Old Pond Road, Suite 201 • Bridgeville, PA 15017 • (412) 220-7323 • Fax: 412-220-7325