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UH EAP CLAIM FORM CLAIMS DEPARTMENT PO Box 30755 Salt Lake City, UT 841300755 18003338724 Use ONLY for Certified EAP Visits. (other claims made on this form will be denied)PATIENT & EMPLOYEE INFORMATION
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How to fill out eap claim form final
How to fill out eap claim form final
01
To fill out the EAP Claim Form Final, follow these steps:
02
Start by entering your personal information, such as your name, address, and contact details.
03
Provide the name of your employer and your job title.
04
Indicate the date of the accident or incident for which you are filing the claim.
05
Describe the nature of the accident or incident in detail, including the location and circumstances.
06
If applicable, provide the names and contact information of any witnesses to the accident or incident.
07
Describe the injuries or damages sustained and provide any supporting medical documentation, such as reports or receipts.
08
Provide details of any medical treatments received and the associated costs.
09
If there were any witnesses to the accident or incident, include their statements or testimonies.
10
Sign and date the form.
11
Review the completed form for accuracy and completeness before submitting it.
Who needs eap claim form final?
01
The EAP Claim Form Final is needed by individuals who have experienced an accident or incident and wish to file a claim for reimbursement or compensation. This form is typically used by employees who are covered under an employee assistance program (EAP) and need to submit a claim for benefits related to the incident.
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