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 Please choose your provider.Appointment Date MM slash DD slash YYYY Provider NameRavi Kant, MDKristen Graziano, CRNPLynette Ohiku, CRNPChristopher Fullerton, CRNPJessica Torick, LPCRachel Shuba, LPCSam Gimigliano, LPCProvider MA Number Date of Service MM slash DD slash YYYY Start Time/Stop Time: Type of Service/Units Billed: 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.
