Secure Online Billing Form

Please give us some information about yourself, the provider group, and authorization data. All information marked with an * is required. Please do not use single or double quotes in the Provider Name field.

Please note — Internet communication is not checked on evenings, weekends, federal holidays, or during states of emergency, such as severe inclement weather.

**If the mailing address you use for taxes or any other tax information has changed, please complete and return a new W9 form.** 

  • Please obtain an authorization number before seeing a client. An authorization number is required to be reimbursed.
  • First Sun EAP must receive this billing form by the sixth of each month.
  • Billing forms received after the sixth may be processed during the next billing cycle.
  • Please do not hold onto billing until all sessions are completed. Sessions or claims submitted after two billing cycles will not be paid.
  • No fees may be charged to the client including fees that may be lost due to faulty billing.
  • Fees may be charged to the client by your office for no shows based on your office policies and procedures.
  • Please make sure to check your work before hitting the submit button.
  • Please print the screen to keep a copy for your records.

Please be aware that electronic communication via the internet cannot be guaranteed to be completely free from potential breach of privacy and confidentiality. If security is a concern for you, please call us at: 800-968-8143 or in the Columbia, SC area 803-376-2668.

CONFIDENTIALITY NOTICE: The information contained in this message may consist of confidential or privileged material and is intended for the person(s) to whom it is addressed. Copying, distributing, disseminating, relying on, or other use of this information by persons other than the intended recipient(s) is prohibited. If you receive this message in error, please notify the sender and delete the entire message from any computer.