EAP Form Anthem – Fill Out and Use This PDF

EAP STATEMENT OF SERVICES RENDERED FORM

Confidential Health Information

Provider Name:

Rendering Provider National Provider Identifier (NPI):_______________________________________

Fax Number:

Billing Address:	___________________________________________________________
	___________________________________________________________
Make Check Payable to:	___________________________________________________________
Tax ID:	___________________________________________________________

Billing Provider National Provider Identifier (NPI):__________________________________________

Reference Number:

(Required)

Important Note for Providers due to HIPAA privacy regulations we can no longer include any EAP member’s name on these confirmation forms. We will only release the member name telephonically.

For the member name that corresponds to the reference number, please feel free to contact Anthem EAP at the toll free number located in the "From:" box on the fax cover sheet.

Scheduled Appt Date (Date Reported by Client):

(Reminder: please call (800) 728-9492, Option 1# and report first session date)

Start Date:		End Date:
Company:		EAP Model:
Sessions Provided:
Date			Date
#1 _______________		#7	________________
#2 _______________		#8	________________
#3 _______________		#9	________________
#4 _______________		#10 ________________
#5 _______________		#11 ________________
#6 _______________		#12 ________________
Provider Signature: __________________________________ Date: __________________
Mail Claims to: EAP Claims
9655 Granite Ridge Drive, 6	th	Floor	Or Fax to: (858) 571-8102
San Diego, CA 92123			For Claim Status: (800) 728-9492 Option 3#

Confidential Health Information Enclosed

IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is STRICTLY PROHIBITED. If you have received this message by error, please notify us immediately and destroy the related message. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-disclosure without appropriate patient consent or as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in Federal and State law.

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

EAP CASE FORM

Phone (800) 728-9492, Option 2# Fax (858) 571-8102

Confidential Health Information

Client Name:					Reference # (Required):	Company:
EAP Assessment: (Check 1 box only)
Alcohol						Marital/Couple Problem
Drug						Violence
Impacted By Alcohol Family/Significant Other						Medical Problem
Impacted by Drug Family/ Significant Other						Legal
Emotional/Psychological						Financial Problem
Impacted by Emotional/Psych of Family/ Significant Other						Work Related Concern
Eating Disorder						Dependent Care
Family Problems						Other Issues
Recommendation: (Primary) (Check 1 box only)
EAP only						Partial hospital psychiatric
Medical doctor referral						Outpatient mental health (office)
Psychiatric meds. Eval/tx						Psychological testing
Alcohol/drug detoxification						Social agency, public program/mental health
Inpatient alcohol/drug tx						Self-help/support group
Structured outpatient alcohol/drug tx						Employer, H.R., management, benefits, etc.
Non Hospital Residential Facility						Childcare/eldercare resources
Inpatient psychiatric tx						Career / vocational counseling
Closing Date:
Benefit Utilization:	EAP Assistance Only			Referrals Not Utilizing Insurance Benefits (Community Resources)
	Referrals Utilizing Insurance Benefits
Referral Information
The Client Was Referred to:
Psychiatrist	Psychologist		MFT/LCSW		Community Resources (Referrals Not Utilizing Insurance Benefits)
PCP/Medical Specialist		Other	Case Closed (EAP Assistance Only/No Additional Referral Needed)

If care was transferred to another licensed professional or behavioral health facility, was the transfer of care coordinated with the new provider by:

Phone	Fax	Report/Letter	Other	Not Applicable
Disposition of Case:		Resolved	Improved		No Change	Deteriorated
		Declined Recommendation			Unable to Contact

Confidential Health Information Enclosed

IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is STRICTLY PROHIBITED. If you have received this message by error, please notify us immediately and destroy the related message. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-disclosure without appropriate patient consent or as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in Federal and State law.

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

EMPLOYEE ASSISTANCE PROGRAM (EAP) PARTICIPANT ORIENTATION

Please read thoroughly before signing and direct any questions to your consultant.

DESCRIPTION OF SERVICES: Your company has contracted with Blue Cross of California (BCC) to provide professional consultation for

employees and their family members regarding a wide range of personal problems. Available services may include: assessment, short-term counseling, and referral. If longer term counseling or specialized services are needed, BCC will refer you to qualified professionals or organizations in the community. BCC will then follow up to assure that your needs are being met. Certain insurance plans require EAP referral in order to utilize your mental health and substance abuse benefits.

FEES: There are no fees to employees or family members for any service received directly from BCC. When BCC refers to resources in the community for ongoing or specialized services, you are responsible for paying any applicable fees. Your group health plan may or may not cover some of the cost of referred services. If BCC makes a referral that utilizes your company benefits, it is your responsibility to verify both your insurance eligibility and the benefits available for behavioral health. This can be done by contacting either the insurance company or your benefit department. It will also be your responsibility to ensure that any provider to whom BCC may refer you is a provider who is consistent with your insurance plan.

CONFIDENTIALITY: When an individual utilizes EAP services, all information will be held confidential unless: 1) the individual authorizes release of information with a signature; 2) the individual represents, in the EAP consultant's opinion, a physical danger to self or others; 3) child abuse/neglect, elder abuse/neglect, or dependent adult abuse/neglect is suspected; 4) a court order for records is issued. If you are employed by a company contracted with or regulated by the Departments of Defense or Transportation or the Nuclear Regulatory Commission, BCC may be required to disclose information about your EAP consultation under the following conditions: a) there is a significant breach of security or safety policies, b) BCC receives an administrative summons or judicial subpoena or order, c) you were referred due to a positive drug test, d) as further defined by your employer. BCC does not make routine "adverse information" reports.

VOLUNTARY PARTICIPATION: The decision to participate in the EAP is voluntary in most cases. Employees participating in the program should not expect any special privileges or exceptions to normal work rules or performance standards. EAP participation is not to be interpreted as constituting a waiver of management's rights to take disciplinary measures, nor shall the program be interpreted as a waiver of the right of any employee to use a complaint procedure within the framework of company policies.

EMPLOYER REFERRAL: When an employee is referred to the EAP by the employer, the appropriate company representative of the

organization may be advised with the employee's consent if: 1) the employee kept the appointment; 2) the EAP consultant has made recommendations; 3) the employee has agreed to follow these recommendations.

GRIEVANCE PROCEDURE: If you are dissatisfied with the service you receive, you may file a grievance in writing or by phone to the

Grievance & Appeals Department, at the following address: Blue Cross of California, BH Grievance and Appeals, PO Box 23330, San Diego,

CA 92193, Fax: (805) 384-3171, Phone: (800) 365-0609, or online at: www.bluecrossca.com/youreap. We are required to inform you of the

following:

California Department of Managed Health Care (DMHC)

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (800) 365-0609 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. I have reviewed and understand the information listed above.

Client Name:			Client Signature: _____________________________ Date: ___________
		(Please Print)
Social Security #		___ ___ ___ -___ ___ - ___ ___ ___ Company Name: _________________________________________

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

EAP Freedom of Choice Information

Your employer-paid EAP counseling sessions have been completed. You and the provider have discussed the nature of your problem(s) and the Provider has recommended additional behavioral health services. The Provider and you should have reviewed all of the alternatives for continuing services including factors of geography, provider specialization, financial arrangements, and insurance coverage. Having carefully considered all of these options, it is important that you understand you are exercising free choice if you decide to continue treatment with your EAP provider. With your decision, the responsibility for payment will transfer to you and/or your health plan.

EAP is not responsible for payment of services beyond the number of sessions allowed under your EAP benefit.

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.