Facility Referrals

To make a referral for a resident of a long-term care facility, please follow these steps:

Fax the client’s face sheet to 614-448-4330 using a cover sheet indicating that the referral is for Lewis and Evans, LLC. Please ensure that the name of your facility is contained within the fax.
Ensure that a signed physician’s order for psychological or mental health services and a signed Authorization for Psychological Services and Billing is available for the clinician. This can be done by placing these items in the medical record on-site or in another pre-determined location where the clinician would have access to these documents. For telehealth, facility staff and the clinician can arrange for the paperwork to be sent to the clinician.
Complete the Reason for Referral form and make it available for the clinician who will be seeing the client.
If the client will be seeing a clinician via telehealth, the Health Signature Page and Informed Consent for Telepsychology will also need to be signed by the client. Facility staff and the clinician can arrange for the paperwork to be sent to the clinician.
The Notice of Privacy Practices and Informed Consent can be printed and given to the clients.

Facility staff can coordinate with the clinician regarding delivery of the signed paperwork to the clinician. Please contact us if you need additional information or have questions.

Authorization for Psychological Services and Billing

Informed Consent for Telepsychology

BILLING/FEES

We accept Medicare as well as several commercial insurances including Humana, Anthem, Cigna, UBH, Aetna, and Medical Mutual. The fee for services will be submitted to a client’s insurance company for payment. Clients are responsible for any part of the fee not covered by insurance including co-payments and deductibles.

If you are seeing a clinician in the outpatient office, you will be billed at the full out-of-pocket rate if you miss an appointment without providing at least a 24-hour notice. Insurance will not be billed for this, and this will be charged to you.

The No Surprises Act was passed by the Federal Government to ensure patients are not surprised by what they are charged for services. This Act currently applies to those who are paying for services out of pocket and not using health insurance. While it is not possible for a clinician to know how many sessions may be needed for treatment, you are entitled to receive a Good Faith Estimate of what the charges for psychotherapy could be. The total cost will depend on the number of sessions and the length of the sessions.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs. equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing as least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059