Patient Intake Form

Please accurately fill out this preliminary form so that we can begin your personalized chart before your initial appointment.

Simply type your answers in the field-boxes below and click submit.
We will process your information as quickly as possible.

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Thank you!

Illuminate NP Psychiatry PLLC

30 S. Cayuga Road,
Suite 106

Williamsville, NY 14221
info@illuminatemhs.org

Phone: 716-903-6035
Fax: 716-463-2225

Billing & Insurance

All fees including copays, deductibles, out of pocket fee and coinsurance will be collected at time of service. These are payable by cash, check or credit card. Your Health Savings Account (HAS) and/or Flexible spending account (FSA) may be used to pay for your appointments with Illuminate NP Psychiatry. We strive to deliver care in a coordinated and cost-effective manner that meets the needs of our clients and their families. Many forms of insurance are accepted for our services. We are also out-of-network for some insurance companies and many clients can collect partial or full reimbursement for services provided. An itemized receipt will be provided to you which can be submitted to your insurance company.

Please bring your insurance card to your first appointment as a copy of it will need to be obtained for billing purposes. Those who do not have insurance but would still like to be seen can contact our office to discuss other options for payment.