Regarding Telehealth Services: Centra will do their best to update our website regarding telehealth reimbursement.

At present, pay parity appears to remain in effect until 12/31/2023 based on Governor Murphy

signing legislation on 12/21/2021. You should be reimbursed at the same rate as an in-person visit.

We still recommend you check with your insurance company regarding any reimbursement for our out of network services.

Regarding Telehealth Services: Centra will do their best to update our website regarding telehealth reimbursement.

At present, pay parity appears to remain in effect until 12/31/2023 based on Governor Murphy

signing legislation on 12/21/2021. You should be reimbursed at the same rate as an in-person visit.

We still recommend you check with your insurance company regarding any reimbursement for our out of network services.

Forms

New Patient Intake Form. Before your first visit, please download and complete this form. 

If you are not submitting your Centra receipts to an insurance company for reimbursement, please submit this additional intake paperwork for a Good Faith Estimate. Choose your clinician below.

OPEN CALCULATOR

Mala Gupta, MD Margaret Harbison, MD Alexander Strauss, MD Lan I. Kycia, MD Albert Wu, MD G. Pirooz Sholevar, MD Deanna Pepe, DO Peggy David, LCSW Meghan McMaster, LPC Danielle Fisher, LCSW J.R. Griffin, LCSW Bianca Faslo, LCSW Caitlin Dunbar, LMFT Deborah E. Blastic, CADC

Medicare Contract.

COVID-19 Informed Consent Form

Credit Card Authorization Form

Medical Release Form. This form is authorization for the release of protected health information. Please download and fill in the fields. Then print and sign and bring with you to the office on your next visit.

Sample Release Form. This is a SAMPLE Release of Information form to serve as a guide.

For Dr. Gupta Patients Only:

Form Uploader

Please follow these steps to upload your forms. (VIEW TUTORIAL VIDEO)

1. Click the button to the form you want. If it opens in your browser, be sure to Download the form first using the download button on the upper right hand corner.

2. Open the downloaded PDF file from your computer, and fill out the form. CLICK SAVE!

3. Open the file again to confirm your changes have saved. 

4. Upload the document using the form below.

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UPLOAD NOW

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