• Insurance Information

    In addition to this form, please provide your physical insurance card and driver's license or other form of picture ID when visiting the office.
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  • Co-payment amount due at time of service: $   or %

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  • We highly recommend that you verify your mental health benefits with your insurance provider prior to your visit so that you are properly aware of your plan's benefits and compensation for mental health services and are not unknowingly charged.

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  • I understand that my insurance company is billed as a courtesy by this office. This office DOES NOT offer benefit verification; it is the patient's responsibility to know what type of Mental Health coverage they have with their plan. If balances go unpaid by my insurance carrier or if I do not have coverage for Mental Health, it is my responsibility to pay the balances on my account. This office will provide patients with a Superbill to submit to their insurance company for reimbursement. Our office has 90 days from the date of service to submit claims to insurance companies. After 6 months of attempting to bill the insurance company without payment or response, I understand that the balance will become my responsibility. We will no longer submit claims after 6 months of non-payment. 

    OUR OFFICE DOES NOT ACCEPT ANY FORM OF MEDICAL ASSISTANCE OR STATE INSURANCE.

    It is the patient's responsibility to keep their insurance information up to date with our office. We will attempt to contact the patient via phone call, email and paper mailing statements for updated insurance information; however, if attempts go unanswered, the balance will become the patient's responsibility. I understand that I am financially responsible for deductibles, co-payments, co-insurance, missed appointment fees, non-covered charges, and any balances not covered under a contractual agreement between Riddle Psychiatry and my insurance payer.

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  • Self Pay Rates:

    Initial Evaluation $250
    30 minute medication management: $125
    31 minutes to 45 minutes medication management: $150
    1 hour medication management: $200
    Follow up Talk Therapy only sessions w/ Betsy Stratton: $150

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  • Please note: If the patient DOES NOT have a secondary insurance, if applicable the patient is responsible for whatever the approved balance is after the primary insurance pays.

    We DO NOT accept any form of Medical Assistance or State Insurance.

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    Czech Italian Slovenian
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    Dutch Klingon Swedish
    English Korean Thai
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  • Payments and Billing:

    Our office accepts payments in person by cahs, debit or credit cards. Effectiive September 2025, we will no longer accept personal checks as a form of payment.

    If you choose to keep a credit card on file, you are authorizing Riddle Psychiatry to automatically charge your card for any amount due on your account, including copayments, fees, and outstanding balances. 

  • I authorize Riddle Psychiatry, LLC to bill my insurance company for charges incurred during the course of my treatment, to provide any information necessary to process my claims, and to collect payment. I authorize my insurance company to honor payments made directly to Riddle Psychiatry.

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