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.