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Self-Referral Form.pdf

Self-Referral Form.pdf
Preview of Self-Referral Form
🔗 Source: 5627605.fs1.hubspotusercontent-na1.net
📊 Size: 167 KB
👤 Author: SCullen-Benson
⬇️ Downloads: 87

Summary

Kepro's Consent to Self-Referral Form is for EAP clients who want to continue seeing their current clinician for ongoing services not covered by their health plan. The client must complete the form after their allotted EAP sessions, acknowledging that Kepro EAP won't cover additional sessions. The clinician must provide two alternate referrals and educate the client on treatment options. The form requires client and EAP affiliate signatures, with options to indicate if the clinician is a participating provider with the client's insurance plan.

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Description

Kepro's Consent to Self-Referral Form is for EAP clients who want to continue seeing their current clinician for ongoing services not covered by their health...

Technical Information

  • File Format: PDF
  • File Size: 167 KB
  • Pages: 1
  • Language: EN
  • Author: SCullen-Benson
  • Total Downloads: 87
  • Last Updated: 1 week ago

Document Overview

This PDF document about Self-Referral Form provides comprehensive information and guidance. Whether you're a beginner or advanced user, this resource offers valuable insights into Self-Referral Form.

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