Wellspring Provider Forms

Below are commonly used forms available for download, or online completion where applicable. 

• Consent Form: This consent form needs to be signed by both you and the client(s) upon each activation (and reactivation) of the benefit, thereby authorizing you to provide and bill for services utilizing the client’s EAP benefit. Without the signed consent form returned to us, we may be unable to provide reimbursement. You can sign the consent form indicating you verbally discussed consent with clients attending virtual sessions. Download the Consent Form
• W-9 Form: The tax ID used on the W9 should match what is filed with the government for yourself or your business. For individuals, it is usually your SSN. If you have registered your practice as a business, it will likely be the TIN given to you. If you are a part of a group practice, it will likely be the groups TIN. For more information visit: https://www.irs.gov/instructions/iw9. 
• Wellspring EAP Provider Application Questionnaire: If you would like to begin the credentialing process with Wellspring, please complete our online application here. It should take about 15 minutes of your time.