Service Encounter Form

Service Encounter Form

Provider ID: 1024568880001
Name*

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

MonthDayYear
Date
Provider:*
Provider Name
Provider

Ryan CrokerDevin FinleyRebecca HeilNicole KrausJake McGrawBandon OggCraig StephensonRachel WybelDr. Shannon Allen - 1027227230003Maria Wunderley CRNP - 1037969460002Kate Savit CRNP 1041050120002Rosey Tritschler CRNP 104320172003Ackerson, JenniferAssalone, RileyBattaglia, IvyCarter, ReneeCheran, KinseyCooper, CherylDestefano, JulieDougherty, AaronEckenrode, SavannahGarrighan, DanielJancay, KalynKahler, DebraKalcich, TaumiKapustik, BrookeLarimore, JenniferLight, JennaMaple, AmandaPerla, AlexanderQuisenberry, JenniferSilva, AmandaSpaw, KeriVickers, DeanaWatt, LeannaWible, EmalieBetler, ClareLott, AdamOther
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:*

MonroevilleSouthsideWexfordCOE/CRS
JADE Wellness Center:

4105 Monroeville Blvd.
Monroeville, PA 15146
1024568880001
1024568880004
1024568880010
1027227230003
1037969460002
1041050120002
1024568880018
104320172002
JADE Wellness Center:

809 Bingham St.
Pittsburgh, PA 15203
1024568880001
1024568880013
1024568880015
1024568880016
1024568880019
1027227230005
1037969460003
1041050120004
104320172003
JADE Wellness Center

101 North Meadows Dr. Ste. 234
Wexford, PA 15090
1024568880001
1024568880011
1024568880008
1024568880009
1024568880011
1024568880017
1027227230004
1041050120003
1037969460004
104320172001
JADE Wellness Center

Certified Recovery Specialist & Center of Excellence program
1024568880001
1024568880018
1024568880004
Signature*

Clear
Should be Empty: