Interactive Encounter Form "*" indicates required fields Neuropsychiatry Center 300 Old Pond Rd # 201 Bridgeville, PA 15017 MA Encounter Form Name* First Last Date of Birth* MM slash DD slash YYYY MA Number Guarantor(parent/guardian name if patient under 14 yrs of age) Patient Signature* Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY For Office Use Only:Provider Name First Last Provider MA Number Date of Service MM slash DD slash YYYY Start Time/Stop Time: Type of Service/Units Billed: Provider Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY 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.
