CG Hylton Inc. EFAP
Provider Billing Form
Provider Name
Invoice Number
Provider Email
example@example.com
Provider GST Number (if applicable)
Client Employer
Invoice Number (if applicable)
Client Name
Client Referral Number (if applicable)
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Additional Information
Client Employer
Invoice Number (if applicable)
Client Name
Client Referral Number (if applicable)
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Additional Information
Client Employer
Invoice Number (if applicable)
Client Name
Client Referral Number (if applicable)
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Additional Information
Client Employer
Invoice Number (if applicable)
Client Name
Client Referral Number (if applicable)
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Additional Information
Client Employer
Invoice Number (if applicable)
Client Name
Client Referral Number (if applicable)
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Date of Service
/
Month
/
Day
Year
Session #
Additional Information
Submit Form
Should be Empty: