* These resources and forms are not required if equivalent documentation is completed by clients. These resources are meant as a resource if a facility or provider does not have an equivalent. MINES does not require copies of this documentation.

Acknowledgement of Receipt of Notice of Privacy Practices

This form must be presented to each client at their first visit.

MINES & Associates EAP Program

Program information to be read & signed by all clients.

Your Rights as a Client

Client rights statement required by law for all clients to read and sign.

Freedom of Choice Affidavit

For clinical exception cases when external referrals are not viable - must be executed in conjunction with Mines case manager.

Authorization for Release of Health Information

To be completed when confidential health information needs to be released. Please note, a release of information is not required for providers to talk to MINES about a MINES client. This form is only for persons trying to access information about another client (i.e. parent for adult child, spouse for spouse) or if MINES is requested to talk to an adult about an adult client on the provider's behalf. This form may also be used as the basis to create a ROI form for yourself. To submit for the purpose of having MINES talk to someone, please send this completed form back by email.

EAP Evaluation/Treatment Plan

Sign into the Provider Portal to request additional authorizations.

Additional Information

Frequently Asked Questions by EAP Affiliates

Providers (Psychiatrists, Psychologists, Social Workers, Licensed Professional Counselors, Licensed Marriage & Family Therapists, Nurse Practitioners, etc.) providing services through the insurance side of members benefit plans.

IMPORTANT INFORMATION ABOUT CLAIMS:

Please submit all insurance related billing to Mines at:

MINES and Associates Claims
P.O. Box 270669
Littleton, CO 80127

Other contact methods:

Toll free: 800-873-7138 x4051
Claims line: 303-832-1068 x4051
Fax: 303-832-9701

To check benefits, eligibility or exclusions, please check the client's insurance card.

Authorization for Release of Health Information

To be completed when confidential health information needs to be released. Please note, a release of information is not required for providers to talk to MINES about a MINES client. This form is only for persons trying to access information about another client (i.e. parent for adult child, spouse for spouse) or if MINES is requested to talk to an adult about an adult client on the provider's behalf. This form may also be used as the basis to create a ROI form for yourself. To submit for the purpose of having MINES talk to someone, please send this completed form back by email.

Medication Evaluation/Management and PPO/Managed Care Evaluation Treatment Plans

No treatment plan is needed for Outpatient Managed Care clients. If this is for EAP, please fill out the treatment plan on the Provider Portal. If this is in regards to psych testing or hospitalization (IOP or higher) services, please contact MINES at 1-800-873-7138 to speak with a case manager.

Additional Information

Provider Procedures

Review required procedures for those providing services to insure reimbursement.

Summary of Responsibilities for Managed Care Clients

Outlines responsibilities of providers, clients and insurance company

The following are resources for various MINES' services outside the standard EAP and PPO services.

CISS (Critical Incident Support Services) Handbook

This handbook contains the essential information around providing CISS services through MINES.

Trainer Handbook

The handbook essential information relevant to those conducting trainings for MINES' clients.

Psychological Assessment Request Form

Use this form to request psychological assessment testing for a MINES' client.

A La Carte Billing Form (Excel file download)

This billing form is to be used for OD, CISS, and other services. Not to be used for EAP or PPO billing.