Insurance Information

Name of Insured*

First NameLast Name

Insured Date of Birth*

Date

Insured Relationship to Patient*

Insurance Company*

ID Number*

Group Number

Co-payment amount due at time of service: $ or %

Did you verify your mental health benefits prior to your visit?*

YesNo

Did you verify with your insurance company that our practice is in network with you insurance?*

YesNo

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.

File Upload: Please upload a front and back copy of your insurance cards to ensure we are billing to the correct company

I understand that my insurance company is billed as a courtesy by this office. If balances go unpaid by insurance carriers or if I do not have coverage, I understand that it is my responsibility to pay for the balances on my account. This office will be happy to provide patients with a Super bill to submit to your insurance company. I understand that I am financially responsible for deductibles, co-payments, co-insurance, missed appointment fees, non-covered charges, and any and all balances not covered under a contractual agreement between “Riddle Psychiatry” and my insurance payer.

Is there a secondary Insurance? If so, please provide the secondary insurance information below.

YesNo

Name of Insured

First NameLast Name

Insured Date of Birth

Date

Insured Relationship to Patient

Insurance Company

ID Number

Group Number

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.

Assignment of Benefits:

I, First Name* Last Name* , authorize Riddle Psychiatry, LLC to bill my insurance company for charges incurred during the course of my treatment and to provide anby information necessary to process my claims and to collect payment. I authorize my insurance company to honor a photocopy of the authorization and to assign my insurance benefits for these charges to Riddle Psychiatry, LLC.

Signature*

Date*

Date

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Arabic	Hebrew	Polish
Bulgarian	Hindi	Portuguese
Catalan	Hmong Daw	Romanian
Chinese Simplified	Hungarian	Russian
Chinese Traditional	Indonesian	Slovak
Czech	Italian	Slovenian
Danish	Japanese	Spanish
Dutch	Klingon	Swedish
English	Korean	Thai
Estonian	Latvian	Turkish
Finnish	Lithuanian	Ukrainian
French	Malay	Urdu
German	Maltese	Vietnamese
Greek	Norwegian	Welsh
Haitian Creole	Persian

Arabic	Hebrew	Polish
Bulgarian	Hindi	Portuguese
Catalan	Hmong Daw	Romanian
Chinese Simplified	Hungarian	Russian
Chinese Traditional	Indonesian	Slovak
Czech	Italian	Slovenian
Danish	Japanese	Spanish
Dutch	Klingon	Swedish
English	Korean	Thai
Estonian	Latvian	Turkish
Finnish	Lithuanian	Ukrainian
French	Malay	Urdu
German	Maltese	Vietnamese
Greek	Norwegian	Welsh
Haitian Creole	Persian