Clinician Invoice Confirmation

Thank you for all you do and the services you provide for our members! We appreciate you!

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The following information is what was submitted on the Espyr Clinician Invoice Form. We recommend that you save this for your records.

Confirmation Id: {entry_id}

Make checks payable to: {Make check payable to:1}

Entity Description: {Entity Description:67}

Billing Address:
{Billing Address (Street Address):4.1}
{Billing Address (Address Line 2):4.2}
{Billing Address (City):4.3}, {Billing Address (State / Province):4.4} {Billing Address (Zip / Postal Code):4.5}
{Billing Address (Country):4.6}

Counselor Name: {Counselor Name:5}


CLIENT INFORMATION

Authorization Number: {Authorization Number:100}

Client Date of Birth: {Client Date of Birth:99}

Name of Employer Providing EAP Benefit: {Name of Employer Providing EAP Benefit:9}


DATES CLIENT SEEN AND CHARGES

Date: {Date:69}

Date: {Date:73}


Date: {Date:75}


Date: {Date:77}


Date: {Date:79}


Date: {Date:80}


Date: {Date:83}


Date: {Date:85}

Total number of EAP visits to date: {Total number of EAP visits to date?:28}

Counselor Signature: {Counselor’s Signature (type name below) (First):30.3}

Date Submitted: {Date Submitted:31}

Billing Reminder

All invoices must be received within 30 days after the session date to be eligible for payment Clinicians may invoice after each session, or after any number of sessions; however, invoices must be submitted to Espyr no later than thirty (30) days after each session to be eligible for reimbursement. Espyr does not compensate clinicians for client no?shows or late cancellations, nor may the client be held financially liable for no? shows or unauthorized services (including, but not limited to cancellation fees and/or administrative fees). Espyr clients are not responsible for the cost of EAP sessions and are not to be invoiced. The EAP closed case form should be submitted with the final invoice.

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