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Affiliate Providers

Affiliate Providers

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. 

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