EAP
 
Provider Forms
 
Provider Forms
 

Provider Form Download Area

Please click on the form you require.  Print and fill out form.  Send completed form to our secure clinical fax at

713-781-4954.  

Adobe Acrobat is required to download the files on this page. You may download it for free by clicking on the Adobe  Acrobat Reader icon.

Download area

CPT Code Change Information

Changes to CPT Codes for 2013

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Changes to CPT Codes for 2013 FAQ

Misc Provider / Facility Form Downloads

Application- Individual Provider.   (All therapist:  Please download the PIP Questionnaire listed below)

Click Here

Application-Facility

Patients Rights and Responsibilities

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Explanation of Benefits - Release of Information

Click Here

MHC Responsibility and Procedures

Click Here

Clinical Feedback Form

Click Here

PIP Questionnaire

Click Here

Refer your Psychiatrist / Therapist

Click Here

Provider Manual Download Area

Introduction

Pre-certification – Authorization of Treatment

Click Here

Adverse Determination

Click Here

Other Services

Click Here

Billing Procedures

Click Here

Forms

Click Here

W-9

For more information or a customized quote please contact us at:

2424 Wilcrest Dr. | Suite 230 | Houston, TX  77042
Toll Free: (800) 324-4327 
info@ieap.com