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EAP Network Participation Request

Please complete the following form only if you are a masters level counselor or above. You must input a correct CAQH number or a valid license number with date of birth. You must have a professional office location. (Note: office space in your primary residence is prohibited)

This form is sent to EAP providers by the EAP when an employee is administratively referred by their employer to the EAP. Complete this form and return to the EAP as soon as possible.

TREATMENT PROVIDER PACKET

This form is sent to Treatment providers by the EAP when an employee is administratively referred by their employer to the EAP, but is participating with the provider through direct services (e.g. health insurance or cash). Complete this form and return to the EAP as soon as possible.

EAP CLAIMS PROCESSING INSTRUCTIONS

All billing to EviCore EAP needs to be mailed the the EAP on a CMS 1500 red and white form.