Abide Psychiatry | SimplePractice

Your info

First name

Last name

Phone

Name you go by

Date of birth

Sex at birth

For insurance verification

Home Address (Street, City, State, Zip Code):

Patients must be 18 years of age or older and physically located in North Carolina, Tennessee, or Florida at the time of their appointment.

Administrative

Referral source

Enter how you were referred to our services

Billing & Payment

Payment method

Insurance & Financial Confirmation: We are in-network with commercial PPO/EPO plans for BCBS and Aetna. All other commercial plans are private pay (superbills provided upon request). Important Notice Regarding Medicare & Medicaid: Abide Psychiatry is opted out of Medicare and does not participate in Medicaid. While Medicare beneficiaries may be seen under a Cash Pay / Private Pay agreement (no claims or superbills can be submitted to Medicare), state regulations strictly prohibit self-pay arrangements for Medicaid-enrolled individuals for covered clinical services.

If you selected an in-network plan above, if you have it easily available, please enter your Member ID and Group Number so we can verify your benefits.

If you selected Private Pay, Cash Pay, self-pay, or are unsure, please type 'N/A'.

Limited to 600 characters

Client Preferences

Is there anything else Dr. Thanupakorn needs to know prior to reviewing your request?

For example: what you'd like to focus on, scheduling preferences, etc.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.