Providers Seeing Self Referrals
What paperwork needs to be returned after seeing a self referral client on behalf of WellSpan EAP?
1) Statement of Understanding - We ask that the client sign the Statement of Understanding at their first scheduled appointment.
2) Completed billing form - Please submit a HCFA 1500 claim form. Sample EAP HCFA 1500 Claim Form.
If you are unable to use a HCFA 1500 claim form, please use your own billing invoice. It must include:
- tax ID number
- pay to address
- provider of service
- client information
- name of employer group providing the EAP benefits
- dates of service
or complete our EAP Referral and Invoice form.
Where do I mail the Claim Form/Invoice? Click here for addresses.
Participating Provider Step-by-Step Procedures. This guide explains the WellSpan EAP referral process.