Affiliate Forms

Employee Services

Providers Overview

EAP Forms

PPO Forms

SBIRT Wellness Coaches


EAP Billing Form
To be submitted to MINES for completed sessions.

Revised Billing Submission Process
Step by step procedure for entering EAP Billing


EAP Evaluation/Treatment Plan
To be completed and submitted to MINES upon completion of authorized sessions or when requesting additional sessions.

Notice Of Privacy Practices
Privacy Practices in compliance with the Health Insurance Portability and Accountability Act [HIPAA] must be made available to each client.

Acknowledgement of Receipt of Notice of Privacy Practices
This form must be presented to each client at their first visit.


MINES & Associates EAP/MAP Program
Program information to be read & signed by all clients

Your Rights as a Client
Client rights statement required by law for all clients to read and sign

Freedom of Choice Affidavit
For clinical exception cases when external referrals are not viable - must be executed in conjunction with Mines case manager

Authorization for Release of Health Information
To be completed when confidential health information needs to be released.

Additional Information

Frequently Asked Questions by EAP Affiliates

Summary of Responsibilities for Managed Care Clients
Information about the authorization process for those being referred in to benefits that have Mines as their managed care entity

Assessment Decision Tree
Tool to assist in determining EAP appropriate short-term cases vs. long-term cases requiring referral out of the EAP into longer term care

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MINES & Associates 10367 West Centennial Road Littleton, CO 80127 800.873.7138
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