New Patient Services Request Form | NeurAbilities Healthcare

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New Patient Services Request Form

Patient Information

Patient's First Name

Patient's Last Name

Patient's Date of Birth:

Patient's Gender:

Patient Street Address:

Patient City:

Patient State:

Patient Zip:

Patient County:

Primary Contact Information

Contact First Name:*

Contact Last Name:*

Relationship to Patient:*

Email Address:*

Daytime Contact Number:*

Preferred time of contact:*

Primary Insurance Carrier:*

Reason for Appointment

Please detail your needs, concerns and medical history so as to best inform our Care Coordinators in scheduling your appointment and pairing you with the most appropriate clinician...

Miscellaneous

How Did You Hear About Us?

Do you want to be on our newsletter mailing list?

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Check Your Insurance Coverage

NeurAbilities is an “in-network” provider with the following insurance carriers:

Amerihealth PPO
Amerihealth HMO
Amerihealth Administrators
Independence Administrators
Independence Blue Cross (IBC)
Horizon Blue Cross Blue Shield of NJ (no medicaid coverage)
Qualcare
Keystone Health Plan East
Empire Blue Cross Blue Shield
Highmark Blue Cross Blue Shield
Capital Blue Cross Blue Shield
Personal Choice
Multiplan
Opt-Out Medicare
Magellan Behavioral Health of PA

NeurAbilities Healthcare is the premier provider of neurological, behavioral and neurodevelopmental services in New Jersey and Pennsylvania, offering comfort, hope and answers that transform the lives of individuals of all ages, and their families.

Our Mission

To transform the lives of patients through precision medicine, behavior sciences, and therapeutic treatments with compassion, dignity, and respect.

Our Vision

To provide hope and achieve positive outcomes for those we serve.

P: 856 346 0005 F: 855 266 6180

Our Core Values

Compassion
Collaboration
Integrity
Excellence
Joy

Notice of Privacy Practices

NOTICE: This website is for informational purposes only and is not intended as medical advice or as a substitute for a patient/physician relationship.

NeurAbilities Healthcare does not exclude, deny benefits to, or otherwise discriminate against any person on the grounds of race, color, or national origin, or on the basis of disability or age in admission to, participation in, or receipt of the services and benefits of any of its programs and activities or in employment therein. This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issued pursuant to the Acts, Title 45 Code of Federal Regulations part 80, 84, and 91.

© NeurAbilities Healthcare. 2021.