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Jonathan Melius PA-C
Date of Service
*
/
Month
/
Day
Year
Date of Visit
Hour Minutes
AM
PM
AM/PM Option
Type of Appointment:
*
Online
In Office
Location of Practice
*
Long Island
Albany
Patient Name
*
First Name
Last Name
Patient Date of Birth:
*
/
Month
/
Day
Year
Type of Visit
*
Psychiatric Intake
Psychiatric Follow-up
Therapy Intake
Therapy Follow-up
Other
If you have picked other please fill out
Would You Like to Avoid wait time at Front Desk? or Pay and Schedule yourself!
*
Yes
Will Do it at the Front Desk
Method of Payment
*
Cash
Credit Card
No Copay
Will owe Practice (Remit payment within 30 days)
My Products
*
Categories:
All
All
Insurance Copay
Private Pay
Suboxone
Will Owe Practice
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Insurance Copay
Insurance Copay
No Copay
$
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
$
300.00
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
Suboxone-Partial Payment
2 weeks price, Must have followup in 2 weeks, partial script for this payment.
$
100.00
Will Owe Practice
Need To Owe Practice
By selecting this option you are at risk for discharge or collections if I do not remit payment within 30 days or more.
$
Free
Credit Card
Patient Email
For Receipt of Payment
Submit
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