Inova Employee Assistance Service Request Form

Thank you for contacting Inova to set up your Innovation Health sponsored Employee Assistance Program (EAP). Please complete the form below to begin your included EAP services. This form is intended for Innovation Health Small Group ACA Client – EAP Inquiries only. We look forward to an opportunity to serve you. You must have JavaScript enabled to use this form. Contact Information Company Name Total Number of Employees (Approximate) Contact Person First Name Last Name Title address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Phone Email Preferred Method of Contact Phone Email Additional Comments or Questions By submitting this form, you are confirming that you would like to receive health and wellness information from Inova. You can unsubscribe if you find it is not meeting your needs. This request form is not monitored by EAP intake staff and should not be used to request any clinical or EAP services for current members.