Get Unicare Eap Statement Of Services Rendered Form 2007-2025

Filling out the UniCare EAP Statement of Services Rendered Form online is a straightforward process. This guide will walk you through each section of the form, ensuring you understand how to provide accurate and complete information.

Follow the steps to accurately fill out your form.

1. Click ‘Get Form’ button to access the UniCare EAP Statement of Services Rendered Form and open it for editing.
2. Fill in the provider's name and the rendering provider's National Provider Identifier in their respective fields. This identifies the provider responsible for the services rendered.
3. Enter the fax number and billing address where documentation should be sent. Make sure all details are correct to avoid any delays in processing.
4. In the 'Make Check Payable to' field, include the name of the entity or individual to whom the payment should be directed. Then, provide the tax ID to ensure the billing is accurate.
5. Complete the billing provider's National Provider Identifier and any reference number as required. These identifiers are crucial for processing claims.
6. Input the client name and scheduled appointment date. It's essential to report the first session date as indicated.
7. Specify the company and EAP model being employed to provide clarity on the services rendered.
8. Document the face-to-face sessions provided, including the dates for up to ten sessions. Write each date in the corresponding field.
9. Sign the document where indicated to acknowledge the submission. Ensure you include the current date to validate the information.
10. Finally, save your changes. You can choose to download, print, or share the completed form as needed.

Start filling out your UniCare EAP Statement of Services Rendered Form online to ensure timely and accurate service documentation.