Service Encounter Form

Service Encounter Form
Name*

First NameLast Name
Recipient Number/Insurance ID*
Type in member ID for insurance here.
Date of Service:*

MonthDayYear
Date
Provider:*
My signature certifies that I received a service or item on the date listed above. I understand that payment from this service or item will be from federal and state funds, or private insurance or self-pay if applicable. Any false claims, statements or documents, or concealment of material may be prosecuted under applicable Federal and State Laws. I have read and agree with the above statement above. In signing this encounter form i certify that the information shown on this invoice is true, correct, and accurate.*

Accept
Primary Site Location:*

MonroevilleSouthsideWexford
JADE Wellness Center:

4105 Monroeville Blvd.
Monroeville, PA 15146
1024568880001
1024568880004
1024568880010
JADE Wellness Center:

809 Bingham St.
Pittsburgh, PA 15203
1024568880001
1024568880013
JADE Wellness Center

101 North Meadows Dr. Ste. 234
Wexford, PA 15090
1024568880001
1024568880011
Signature*

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