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Make edits, fill in missing information, and update formatting in US Legal Forms—just like you would in MS Word.

Download a copy, print it, send it by email, or mail it via USPS—whatever works best for your next step.

Sign and collect signatures with our SignNow integration. Send to multiple recipients, set reminders, and more. Go Premium to unlock E-Sign.

If this form requires notarization, complete it online through a secure video call—no need to meet a notary in person or wait for an appointment.

We protect your documents and personal data by following strict security and privacy standards.
“Providers” can include doctors, psychologists, or physical therapists, and health care facilities, like hospitals, urgent care clinics, or pharmacies. Insurance companies may have different networks for different plans, so make sure you search the provider network of each specific plan you compare.
Aetna® group of companies. Aetna is proud to be a part of the CVS Health® family of companies.
Availity is now our sole provider portal Submit claims, send supporting documentation and check status. View remittances and EOBs. Request authorizations and referrals. Access Aetna specific resources.
Aetna and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-branded walk-in clinics) are both within the CVS Health family.
Aetna offers Medicaid insurance plans in many states. Aetna also runs Children's Health Insurance Plan (CHIP), Medicare Advantage, behavioral health and long-term care programs in some states.
Aetna Signature Administrators® is the brand name for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
Use the CPT Code 99404 in order to indicate the sessions is billed under EAP.
EAP claims should be submitted through Provider Express or on a CMS-1500 claim form using the standard "HJ" modifer in section 24D.
You can submit claims online or resubmissions through ConnectCenter.