Affiliate Case/Billing Forms - Inova EAP and Work Life Services
Mandatory IEA Forms
These forms must be returned to IEA upon case closure.
IEA Contact/Billing Form: This form serves as your invoice for services. For affiliate reimbursement to take place, it must be completed after the clinical assessment is done; the billing section of the form should be filled out after services are completed. Turnaround time for reimbursement is 30 calendar days from the date IEA receives your Billing Form. Click here to read directions on how to fill out the form.
IEA Statement of Understanding: Before starting the initial assessment interview, have the EAP client read and sign the IEA Statement of Understanding, which describes the role and scope of IEA services and helps define the client-counselor relationship and the purpose of the program. Make a copy of the signed form for the client (do not give the EAP client the original). The client must sign this form before you can provide services, and you must provide it to IEA for payment to be authorized.
Additional Documentation
Authorization to Release/Disclosure Protected Health Information: Depending
on the nature of the case, you may need the client to sign this form, which gives
permission for IEA to communicate with a third party, such as the client's
employer, or to refer the client to a treatment provider. Under the terms of our
affiliate agreement, it is not necessary to complete this form for you to
communicate to IEA.
Please mail or fax the forms to:
Inova Employee Assistance
3929 Pender Drive, Suite 310
Fairfax, VA 22030
Fax: 703-246-8809
