Affiliate Case Billing Forms
The two forms below must be returned to IEA upon case closure.
Provider Invoice for EAP Services
This form serves as your invoice for services. For affiliate reimbursement to take place, it must be completed after the last EAP session and the case is closed. Turnaround time for reimbursement is 30-45 calendar days from the date invoice is received.
IEA Statement of Understanding/Verification of EAP Sessions
Before starting the initial assessment interview, have the client read and sign the IEA statement of understanding, which describes the role and scope of IEA services and helps define the client-counselor relationship and the purpose of the program. Make a copy of the signed form for the client (do not give the client the original). The client must sign this form before you can provide services, and you must provide it for payment to be authorized. PLEASE NOTE: You are now required to have the client sign off on their session date(s). This form must be completed in its entirety in order to receive reimbursement.
Authorization to release/disclose protected health information
Depending on the nature of the case, you may need the client to sign this form, which gives permission for IEA to communicate with a third party, such as the client's employer, or to refer the client to a treatment provider. Under the terms of our affiliate agreement, it is not necessary to complete this form for you to communicate to IEA.
Mail or fax completed forms
Please mail or fax all forms to:
Workplace Options – Network Advantage
3020 Highwoods Blvd.
Raleigh, NC 27604