• PROVIDER BILLING FORM

    Network Service Log
  • All information marked with an * is required.

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  • PLEASE UPDATE ANY CONTACT INFORMATION.

    **If the mailing address you use for taxes or any other tax information has changed, please complete and return a new W9 form.** 

  • 1. Please obtain an authorization number before seeing a client. An authorization number is required to be reimbursed. 

    2. First Sun EAP must receive this billing form by the sixth of each month.

    3. Billing forms received after the sixth may be processed during the next billing cycle.

    4. Please do not hold onto billing until all sessions are completed. Sessions or claims submitted after two billing cycles will not be paid.

    5. No fees may be charged to the client including fees that may be lost due to faulty billing.

    6. Fees may be charged to the client by your office for no shows based on your office policies and procedures.

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    • Please make sure to check your work before hitting the submit button.
    • Please print the screen to keep a copy for your records.

    Please be aware that electronic communication via the internet cannot be guaranteed to be completely free from potential breach of privacy and confidentiality. If security is a concern for you, please call us at 803-978-9900.

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