PROVIDER BILLING FORM – APPROVED

All information marked with an * is required.

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Provider Name*

Practice or Group Name

Provider Phone Number*

(123)123-4567

Provider Email Address*

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.

	Authorization # *	Client Name or Title of Training	Employee's Company	Service Date	Session Minutes
1
2
3
4
5
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8
9
10

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