Affiliate Billing

Step 1 of 4

25%

Affiliate Provider Information

Payment Payable to (Group Name if applicable)*

Affiliate Name*

First Last

Affiliate Address*

Street Address Address Line 2 City State ZIP Code

Affiliate Email Address*

Enter Email Confirm Email

SS# / Tax ID#*

Rate per session*

Client Information

Client Number*

Client Name*

First Last

Employee Name (if different)

Name of Employer Providing EAP Benefit*

Confirmation of Statement of Understanding

If provider explained confidentiality and limitations via telehealth, please check here

By checking here, you are digitally initialing to show confirmation.

OR If client signed the Statement of Understanding Upload here

Accepted file types: pdf, doc, txt, jpg, Max. file size: 50 MB.

Download the Statement of Understanding form

Client Session Information

Dates Client Seen, Charges and Brief Summary of Session. To add additional sessions, click the check box below.

Session Number*

Date*

MM slash DD slash YYYY

Fee*

Session Summary*

Additional Sessions

Click to add additional sessions

Session Number*

Date*

MM slash DD slash YYYY

Fee*

Session Summary*

Further authorization may be considered if the Affiliate calls and speaks with the Case Manager assigned to the case after the 2nd session (3rd session if you are in California*). Use the + button to enter details on additional sessions now. Please fill out all fields for each session.

Session Number

Date

Fee

Session Summary

Total Amount Due*

Total Number of EAP visits to date*

This completes the EAP Sessions*

Yes

*Employees in California receive a total of 3 EAP sessions which are authorized up front to complete the assessment. Call the Case Manager for California after the 3rd session to review the case and discuss recommendations for ongoing care.

Disposition and Recommendations

Date Case Closed

MM slash DD slash YYYY

Case Opened On

Work Performance (check all that apply)

Absent

Tardy

Presenteeism

Safety Violations

Problems Relating to Other Employees

Quality/Quantity of Work Decreased

Alcohol/Drugs Suspected on the Job

N/A – Family Member

No Problems

Personnel Action (check all that apply)

Employee was counseled at work

Verbal/Written Warning

Suspension

Demotion

Termination

Resignation

No Action Taken

N/A – Family Member

Aware of EAP (check all that apply)

Prior Participation

Printed Materials

Electronic Materials

Posters

Company Intranet

Supervisor/HR Suggested

Co-Worker Suggested

Family Suggested

Training/Orientation/Webinar

Other On-Site Activity

Outcome

Referral Made To

Primary Assessed Problem

Secondary Assessed Problem (if applicable)

Tertiary Assessed Problem (if applicable)

Referred to

Closing Notes

Sign and Confirm Invoice

Please use the "Previous" and "Next" buttons below to review the form in its entirety and provide your name below as your digital signature prior to submitting this invoice. By signing your name below, you are digitally signing this invoice. This form must be submitted within forty-five (45) days of the last date of service to be eligible for reimbursement. Please make sure to check your entries before hitting the submit button. Please print the screen to keep a copy for your records.

By clicking “Submit” you acknowledge and agree that you have already entered into a Business Associate Agreement (“BAA”) with Workplace Solutions. This Submission is a permitted disclosure as set forth in Section 2 of the BAA because you are using and/or disclosing any applicable PHI merely to comply with proper management and administration, and all information submitted will be held confidentially and used only as required by law or for purpose for which it was disclosed.

For resources on managing current events, log in to the portal using your company code.

Affiliate Online Billing Form

Affiliate Provider Information

Client Information

Client Session Information

Disposition and Recommendations

Sign and Confirm Invoice

For more information about our services, please fill submit the form below. We will respond to you within 1 business day.

Become an Affiliate

To become an affiliate, please download and fill out the PDF form below.

Once completed, upload the form here.

Get a Quote

For resources on managing current events, log in to the portal using your company code.

Employee Services

HR Professional

Affiliate Online Billing Form

Affiliate Provider Information

Client Information

Client Session Information

Disposition and Recommendations

Sign and Confirm Invoice