Financial Responsibility Form

Please fill out and submit the form below prior to your appointment date / time. You may also download and print the form to manually fill it out and bring it with to your appointment using this link: DOWNLOAD FORM

Most health insurance plans today have clauses which limit coverage to "usual and customary fees for reasonable and necessary services." Because some of the treatments used in psychiatry are not recognized by some insurance companies, we cannot guarantee the amount or availability of coverage for our services and treatment under your health care insurance policy. You are responsible for payment of our charges at the time of service regardless of insurance coverage.

Payment may be made by check, cash or credit card for services or office visits. If insurance coverage is available for the services rendered, we can provide a receipt with the required information for you to present to your insurance company for possible reimbursement. You will be responsible for the cost for any special reports and/or corrected claims that require professional time on your behalf to insurance companies or others. You are entitled to know the cost of all services in advance.

COST FOR SERVICES:

90 minute psychiatric evaluation        $515.00

60 minutes psychiatric evaluation        $335.00

50 minutes medication/therapy        $300.00

75 minutes medication/therapy        $420.00

30 minutes medication/therapy        $190.00

15 minutes follow up appointment        $95.00


I have read and understand the information listed above.