Contract Renewal Billing Alert Please submit this form only when all Census and Billing Data has been collected and client's current contract renewal is ready to be finalized and billed.ESI DetailsSales Rep(Required) Account Manager of this ClientDirect Supervisor of Rep(Required) Angela Delahunt Karen Keis Patty Reardon Who is your Manager?For Management ReviewRate Change(Required) Increase Decrease No change Is Client's Rate changing this yearReason For Rate Decrease Poor Utilization Decrease in EE's Other Why did the rate decrease for this clientReason For Rate Increase Increased Utilization Increase in EE's Other Why did the rate increase for this clientIndicate Reason Reason for rate changeClient InformationClient Name(Required) Please Copy Directly from EAPXClient Renewal Date(Required) Month and Year of RenewalVertical(Required)...EDUHCHEDPSUnionAPTCWhat vertical is this client underBroker(Required) Yes No Does this client have a broker?Broker Who is the Broker?Counseling Contract SpecificsCounseling Sessions(Required) Up to Guaranteed Counseling Sessions Number of Counseling Sessions to Include on Contract 1 2 3 4 5 6 How Many counseling Sessions On ContractType of Counseling(Required) Face to Face Telephonic Counseling TypeCounseling Special TermsSpecial Counseling Terms Special Counseling Terms - not listed aboveTrauma DetailsNumber of Trauma Responses Included(Required) Unlimited 0 1 2 3 How many Trauma responses included?Trauma Fee(Required)...$0.00 (only if Unlimited)$250.00Trauma Fee GCN Billing SpecificsGCN Trainings(Required)...YesNoDoes Client get GCN TrainingsGCN FeeFee For GCN TrainingsSAP Billing SpecificsSAP Fee(Required)...$0$450$850What is the SAP FeeContract TotalsNumber of EES on Current Census(Required) Current Census DataAnnual Contract Total(Required)Total Annual Contract Amount for ClientLast Year EEs Prior Year's Census DataOther Billing SpecificsBilling(Required) Flat PEPY Is this client billed Flat or PEPYCost per Employee for PEPYAmount Per EECYT(Required) Monthly Quarterly Semi-Annually Annually How often billing occurs for this clientNotes for Accounting
