EAP Patient Submission New Directions EAP Submission Provider name Provider Email Patient Name Patient URL (Copy the web address from internet browser) Patient Authorization # Did you send to a copy of the authorization form to MCMSouth? Yes No Assessment: Check 1 box only Addiction other Anger Anxiety Career Development Depression Education Family Financial Grief/ Loss Legal Partner/ Marital Physical Health PTSD/ Trauma Stress Substance Use Work/ Life Workplace Issues Other Anthem Blue Cross required information (check 1 box only) Resolution: Check 1 box only Resolved in program Withdrew If your patient is using Blue Cross (Anthem) Please complete this section Continue as: Check 1 box only Self-Pay With different provider Insurance If your patient is using Blue Cross (Anthem) Please complete this section Recommend: Check 1 box only None Self Help Other 12 Step Group Higher Level of Care Career Support Services Other community based support/ groups Educational Support Services Ongoing Outpatient Treatment Please complete this section Sessions Date(s) (Please list if not shown in software) The EAP sessions to be billed Is this the last EAP session for patient? Yes No Share this:TweetShare on TumblrPocketPrintWhatsAppMoreReddit