PARTICIPANT LOG IN

  • 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. Espyr does not pay for No Shows or Late Cancellations.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • 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.

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