Applications & Forms

For your convenience, the forms to the right are available to download as Adobe Acrobat PDFs.

If you are unable to view PDF files, download the free viewer from Adobe.

Print your application and mail it with your license, resume, and proof of professional liability insurance to:

ERS, Inc.
Provider Relations Department
29 East Madison, Suite 1600
Chicago, Illinois 60602

Questions about the application process? Call us at (866) 377-5550 or email to

Accepting an Affiliate Referral

Once you have been accepted onto ERS’ Affiliate panel, you may begin to receive EAP case referrals. Complete the paperwork as directed below:

  1. The Client Data Form is a 2-page assessment that should be completed after the first or second authorized sessions. For session #3 or higher, make additional copies of the 2nd page.
  2. The Statement of Understanding, the Release of Information, and the Privacy Notice must be reviewed and signed by the client at the first session.
  3. At the conclusion of the authorized sessions, submit your bill within 60 days of the final session. Bills submitted on forms other than the ERS Billing Statement will not be paid.
  4. Mail the original Client Data Form and Statement of Understanding along with the ERS Billing Statement to the EAP Counselor within 60 days of the final session. Bills are processed after all required clinical paperwork is received.

Affiliate Application Forms

Clinical Forms