Employee Assistance Program (EAP) Application

Documents Needed

Copy of Insurance

Hidden

Account ID (Hidden)

Provider Practice Information

Please include the following information for all practices which you may be providing services.

Primary Address

Practice Name

Location Street Address

Address Line 2 (Suite #)

City

State

Zip Code

Credentialing Email

Phone:

Fax:

Start Date

Provides Telehealth

Tax ID (TIN/EIN)

Please do not place a - in your Tax ID number

W9 Upload

Please list your SSN or your TIN for which you are billing, on your W-9. A W-9 cannot be accepted listing both, it has to be one. If you need a new form, it can be downloaded here: https://www.irs.gov/pub/irs-pdf/fw9.pdf

Primary Schedule

Days of the Week

Start Time

End Time

Is your billing address the same as your practice address?

Billing Address

Location Street Address

Address Line 2 (Suite #)

City

State

Zip Code

Phone:

Fax:

Do you have any other addresses?

Secondary Address(es)

Practice Name

Location Street Address

Address Line 2 (Suite #)

City

State

Zip Code

Credentialing Email

Phone:

Fax:

Start Date

Tax ID (TIN/EIN)

Please do not put a - in your Tax ID number.

Provides Telehealth

W-9 Upload

Please list your SSN or your TIN for which you are billing, on your W-9. A W-9 cannot be accepted listing both, it has to be one.

Secondary Schedule

Days of the Week

Start Time

End Time

Additional Information

Please answer the following questions completely. If you answer "yes" to any question, please provide a detailed description, including current disposition, in the text field below the question.

How many years of experience do you have in providing EAP services, defined as solution focused brief therapy?

Have you completed training meeting the requirements outlined in the Department of Transportation (DOT) regulations 49 CFR Part 40.281(c)? If yes, please return your original and most recent certifications

Original Certificate

Most Recent Certificate

Do you see clients in your home?

a. Is there a separate entrance for the home office?

b. Is the home office handicap accessible?

c. Is there a waiting space for clients away from living quarters?

d. Are clients scheduled at times when members of the house are not at home?

e. Where are files located?

i. Is the file location secure (locked)?

f. Do you have any animals in your home?

Does the animal interact with clients?

Is the animal certified as a therapy animal?

Do you have a release signed prior to interactions?

Acknowledgement

I hereby certify and attest, by checking this box I have reviewed all the information above and the information is true and accurate. I understand that any information provided pursuant to submission of this provider data that is subsequently found to be untrue and/or incorrect could result in my termination from the New Directions’ behavioral health network. By checking here, you are verifying that you are the provider who completed this form or, if completing for a provider, that you have the authority to complete this form on behalf of that provider.

I agree

Name

Sr	PsyD	PhD
MSW	MSN	MS
MFT	MEd	MDiv
MA	Jr	III
II	EdS	EdD
DSW	Dmin