Insurance Call Form

Relationship ReDiscovery Center

Insurance Call Form
Client Name (as noted on insurance card)
Date Ins Called

Month Day Year
Date
Insurance Company Name
If Other: Insurance Company Name
Insurance Member ID#
Group#
Payor ID#
Usually small print on back of card, if noted
Provider Service Phone number *
* If listed on your card. Provider Service Phone number maybe listed as "Behavioral Health" or "Customer services" on back
Step 1: Please call your insurance company and let them know you are a member calling about "routine outpatient mental health counseling services".
Step 2: Ask, "Is Bill Gould LCPC an in-network provider? His address is 444 Main St, Lewiston."

Bill Gould is IN-NETWORK Bill Gould is OUT-OF-NETWORK
Step 3: Ask, "Is preauthorization required for routine outpatient mental health counseling services"?

No preauthorization is required Yes preauthorization is required
Preauthorization number
Number sessions
Preauthorization start date

Month Day Year
Date
End date

Month Day Year
Date
Step4: "Do I have a deductible?"

Yes No
In Network Deductible amount
In Network remaining Balance
Out Network Deductible amount
Out Network remaining Balance
Step 5: "What is my co-pay or co-insurance?"
Step 6: "Does my plan cover TeleTherapy and or phone for mental health counseling?
Does my plan cover TeleTherapy (Video)?

Yes No
End date when TeleTherapy will no longer be covered

Month Day Year
Date
Does my plan cover Phone Therapy?

Yes No
End date when Phone Therapy will no longer be covered

Month Day Year
Date
Step 6: For couples only: ask, "Does my insurance policy cover "Family Counseling"?

Yes Family Counseling is covered No Family Counseling is NOT covered
As always, please contact Bill Gould LCPC if you have any questions.
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