Healthcare EAP Renewal

Healthcare EAP Renewal

Participant Information

Participant Name:

Date of Birth:    Gender:

Employment and EAP Coverage

Employer / Organization:

EAP Provider:    Member/ID Number:

Renewal Effective From: to

Medical and Behavioral Health History

Are you currently receiving mental health treatment? Yes

Consent to EAP Services

I request renewal of Employee Assistance Program services and authorize the EAP provider to deliver assessment, short-term counseling, referral and coordination of care as clinically appropriate. I understand that:

- Benefits and risks of counseling include gains in functioning and symptom reduction, but progress is not guaranteed and there may be temporary increases in distress. The EAP is intended for short-term intervention and will refer for ongoing care when appropriate.

- I have the right to withdraw consent at any time by providing written notice. Withdrawal will not affect disclosures already made based on this authorization.

I consent to receive EAP services: I agree

Release of Information and Coordination of Care

For purposes of care coordination, quality assurance and outcome measurement, I authorize release of pertinent clinical information (limited to treatment summary, attendance, and relevant safety concerns) between the EAP provider and:

I authorize the EAP provider to obtain or disclose my protected health information as described above: Authorize

HIPAA Acknowledgment

I acknowledge that I have been provided with information regarding privacy practices and understand how my protected health information will be used and disclosed for treatment, payment, and health care operations as necessary for my EAP participation.

Acknowledgment of receipt of privacy notice: Acknowledged

Telehealth and Electronic Communications

I consent to telehealth sessions when clinically indicated. I understand telehealth involves use of electronic communications and carries risks including technology failure, confidentiality limitations, and potential privacy breaches.

Consent to telehealth: I consent

Costs, Limitations, and Expiration

EAP services are provided subject to program limits established by the employer and EAP provider. If services fall outside covered EAP benefits, the EAP provider will notify me of any fees, billing arrangements or referrals to other providers.

Voluntary Revocation

I understand that I may revoke this authorization at any time by providing written notice to the EAP provider, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made based on this authorization.

Additional Information

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