• Please complete all required fields and submit

    This form must be submitted within thirty (30) days of each date of service.

  • Name MUST match the tax ID owner name on file with IRS for the TIN listed below
  • if different than "make check payable to"
  • Client Information

  • If different from client
  • Dates Client Seen and Charges

    Do not include previously invoiced dates. EAPC does not pay for No Shows or Late Cancellations.
  • Sign and Confirm Invoice

    Please review the form in its entirety and provide your name below as your digital signature prior to submitting this invoice.
  • By entering your name above, you are digitally signing this invoice.
  • INVOICES MUST BE SUBMITTED WITHIN 30 DAYS OF EACH DATE OF SERVICE TO BE ELIGIBLE FOR REIMBURSEMENT.
  • This field is for validation purposes and should be left unchanged.

For more information about our billing process, or to sign up for direct deposit, please contact Provider Billing at providerbilling@espyr.com.