Provider Application

Dear Prospective Provider,

Thank you for your interest in becoming one of our preferred providers with   Groff & Associates ! Once you are in our network, we will provide you    clients based on your specialty locally and nationally.  We desire to serve our clients with the best possible proactive healthcare.   

What We Need:

To continue in this process with us, we require the following information:

1. Signed Provider Information form     Provider Information (DOC)
2. Signed W-9                                                W-9 (PDF)
3. Signed Provider Agreement    
4. Proof of Insurance Liability Coverage (if required, by state law)
5. Photocopies of any relevant licenses, credentials, and certificates             

 How our EAP Works:

• The EAP client calls our EAP hotline phone number.
• Our EAP Assessment Manager matches the client to the EAP Provider based on client need, location and specialty.
• Our EAP Assessment Manager will contact you by phone and email.
• You agree to respond to the EAP Assessment Manager within 24 hours with your availability.
• The EAP Assessment Manager will give the EAP Provider the pertinent information regarding the client and will have the client contact the EAP Provider directly to schedule an appointment.
• No monies are exchanged between the client and EAP Provider at the time of service.  You agree based on your specialty to contract with Groff & Associates at a fixed rate.
• The EAP Provider is responsible for invoicing Groff & Associates every two weeks to receive reimbursement. 
• Groff & Associates will issue a reimbursement check every Friday for the previous two week pay period.