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Affiliate Providers

Affiliate Providers

Providers Seeing Supervisory Referrals

What paperwork needs to be returned after seeing a supervisory referral client on behalf of WellSpan EAP?

1) Client Status Report
– one Client Status Report is required after each EAP session. This is a simple form which the provider completes and faxes to WellSpan EAP. Simply check the appropriate response, include the date and time of next scheduled appointment, and fax to WellSpan EAP. Comments may be entered at the bottom, but should not include diagnosis information.

2)Statement of Understanding
- We ask that the client sign the Statement of Understanding at their first scheduled appointment.

3) 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 explans the WellSpan EAP referral process.




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