Patient Intake Form

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Complete this HIPAA compliant form to help Kapoor Cares LLC expedite your intake and verify your insurance/payment method within 24 hours.
Thank you for contacting Kapoor Cares LLC - mental health care services for all ages. By filling out this form right away, you help our office expedite the intake process and verify your medical insurance information within 24 hours.
Full Name

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Date of Birth

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Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
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Home Address

Street Address

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KAPOOR CARES LLC — TERMS & CONDITIONS SUMMARY

Services
Psychiatric and psychotherapy care across the lifespan — depression, anxiety, PTSD, bipolar disorder, dementia, substance abuse, self-harm/suicidality, and more. Available in inpatient, outpatient, assisted-living, and office settings. Individual and couples therapy also offered.

Medications
Shared, patient-centered decision-making. Providers explain risks, benefits, dosage, side effects, drug interactions, and withdrawal risks in a language the patient understands before prescribing. Questions can be directed to the office.

Cancellation / No-Show Policy

Cancel at least 24 business hours in advance
Late cancellations/no-shows: $50 fee (not billable to insurance)
More than 2 unexcused missed appointments may result in dismissal from the practice
Billing & Insurance (Non-Medicare Patients)

Payment required for each session
Practice bills insurance as a courtesy but cannot guarantee accuracy of coverage info
Patient is responsible for co-pays, deductibles, and any denied claims
Patient must confirm prior authorization/deductible requirements directly with their insurer
Financial hardship situations can be discussed with the office
Medicare Patients

Patient responsible for copays/deductibles
By signing, patient authorizes Medicare billing and release of medical info as needed
Patient consents to psychiatric evaluation and follow-up care, with claims forwarded to Medicare for reimbursement
Upload a clear picture of the back side (e.g., ID, insurance card, or relevant document)

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What are the reasons you are contacting Kapoor Cares LLC?

Other
Type your preferred weekdays and weekends appointments time range. We will try our best to accommodate your preferences.
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