Check In Priyadarshan Bajpayi MD

Check In

Priyadarshan Bajpayi MD
Date of Service*

MonthDayYear
Date of Visit
Hour MinutesAM/PM Option
OnlineIn Office
Long IslandAlbany
Patient Name*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Psychiatric IntakePsychiatric Follow-upTherapy IntakeTherapy Follow-upOther
If you have picked other please fill out
YesWill Do it at the Front Desk
CashCredit CardNo CopayWill owe Practice (Remit payment within 30 days)

Psychiatry is a specialty copay found on your insurance card Copayments are due prior to your visit, please select one of the following options in the dropdown menu below.*

Insurance Copay

Insurance Copay

No Copay Only choose if you have no copay or you may be grounds for discharge

$ Free

Insurance Copay

$10.00

Insurance Copay

$15.00

Insurance Copay

$20.00

Insurance Copay

$25.00

Insurance Copay

$30.00

Insurance Copay

$35.00

Insurance Copay

$40.00

Insurance Copay

$45.00

Insurance Copay

$50.00

Insurance Copay

$55.00

Insurance Copay

$60.00

Insurance Copay

$65.00

Insurance Copay

$70.00

Insurance Copay

$75.00

Insurance Copay

$80.00

Insurance Copay

$85.00

Insurance Copay

$90.00

Private Pay

Private Pay-New Intake

$600.00

Private Pay-Followup

$175.00

Suboxone

Suboxone-Online

Online requires 50 dollar increase in charges, due to missing in person appointment

$250.00

Suboxone

$200.00

Total

$0.00

Credit Card

Patient Email
For Receipt of Payment
Should be Empty: