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Locations
Lackawanna County
Moosic, PA
Downtown Scranton, PA
Clarks Summit, PA
Carbondale, PA
Blakely, PA
Pike County
Matamoras, PA
Northampton County
Bethlehem, PA
Columbia County
Berwick, PA
Bloomsburg, PA
Luzerne County
Kingston, PA
Pittston, PA
Wilkes-Barre, PA
Wyoming County
Tunkhannock, PA
Montour County
Danville, PA
Contact
Employee Assistance Plan Information
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Employee Assistance Plan Information
Employee Assistance Program
Client Name
(Required)
Please enter your name here.
First
Last
Best number to reach you at
(Required)
Subscriber Name
Enter the person who has the EAP benefit here (if different from above. If it is the same, you may leave blank.)
First
Last
EAP Name
(Required)
Number of Approved Sessions
(Required)
Please enter the number of sessions your EAP has approved you to have here.
Authorization Number
(Required)
This is the number you will get from your EAP that allows us to bill for your covered sessions.
Start Date
(Required)
This is the earliest you can have a session covered by your EAP
MM slash DD slash YYYY
End Date
(Required)
This is when your EAP benefits will expire, the last date you can have a covered session.
MM slash DD slash YYYY
Please also bring any forms or paperwork from your EAP to your first session. If you have any questions or are missing any of the information we need above, please contact us at 570-521-4637!
Consent
(Required)
Although this office will process claims by billing insurance companies, I understand that payment for insurance deductibles and co-pays are my responsibility. We do not impose any charge for no-show/late cancellation appointments, nor do we use collection agencies for outstanding late payments. By signing below, I give permission for submission to my Employee Assistance Company.
I agree to the payment policy.
Consent
(Required)
I understand my privacy and the Protected Health Information in the HIPAA information provided and available. I understand billing information (i.e. diagnosis) may be shared with others who need to arrange payment for my treatment by a third party payer (insurance companies / Employee Assistance Programs). This office uses the professional billing services of Mental Health Billing Services, LLC. I understand that if I am concerned about shared information, I have the right to ask for and receive further explanation.
Notice of Privacy and HIPPA
Date
(Required)
MM slash DD slash YYYY
Signature
(Required)
