Interactive Encounter Form

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

Name*
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(parent/guardian name if patient under 14 yrs of age)
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For Office Use Only:

Provider Name
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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.