Interactive Encounter Form

Neuropsychiatry Center
300 Old Pond Rd # 201
Bridgeville, PA 15017
MA Encounter Form

Date of Birth*

MA Number

Guarantor

(parent/guardian name if patient under 14 yrs of age)

Patient Signature*

Date

Please Choose Your Provider:

Provider Name

Provider MA Number

Date of Service

Start Time/Stop Time:

Type of Service/Units Billed:

Provider Signature

Date

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.

Interactive Encounter Form

Please Choose Your Provider:

New Patients: Request Initial Appointment

Existing Patients: Update Your Information

Pay Your Balance

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