The Formula for Life EAP Insurance Form

If you would like to use your insurance, please do the following:

Call customer service number on the back of your insurance card, and:

1. Request EAP Authorization #

2. Ask how many sessions are covered

Once you have that information, please complete the form below.

Legal First Name *

Legal Last Name *

Email *

Phone *

Birthday *

Insurance *

Member ID

Group ID

Authorization # *

# of sessions approved *