Healthcare EFAP Agreement

HEALTHCARE EFAP AGREEMENT

This Employee and Family Assistance Program Agreement (the Agreement) is entered into between Patient Name: and EFAP Provider: . The parties agree as follows.

1. Patient Information

Date of Birth:   Gender:

2. Insurance Information

3. Medical & Behavioral History

In the past 12 months have you experienced thoughts of harming yourself or others? Yes No

4. EFAP Services, Consent, and Limits of Confidentiality

Description of Services: EFAP provides short-term assessment, brief counseling, referral to community resources, crisis intervention, and case coordination. Purpose/Reason for referral:

I understand the benefits and limitations of EFAP services. Benefits may include short-term symptom relief, problem-solving strategies, and referrals to long-term care when indicated. Limitations include scope of short-term support, potential need for referral outside the EFAP, and that EFAP does not guarantee continued or indefinite treatment.

I acknowledge the following legally required limits to confidentiality and authorize disclosure as necessary:

Duty to warn and protect identifiable individuals from serious threats of harm.

Reporting obligations for suspected child abuse, elder abuse, or dependent adult abuse.

If required by a lawfully issued court order or subpoena.

Telehealth: I consent to receive EFAP services via telephone or videoconference where offered, and I understand the advantages and confidentiality risks associated with telehealth.

I consent to telehealth services.

5. Authorization to Disclose / Communicate

I authorize the EFAP Provider to share limited information as necessary to coordinate care, referrals, and safety planning with the following parties as indicated below. I understand that my written authorization is required for disclosure of psychotherapy notes except as otherwise permitted by law.

Authorization Expiration Date:

Right to Revoke: I understand I may revoke this authorization in writing at any time, except to the extent that EFAP Provider or others have already acted in reliance on it.

6. Billing, Fees, and Cancellation

EFAP services provided under this Agreement are typically offered at no direct cost to the patient through employer sponsorship. Where services are not covered or additional ancillary services are requested, fees may apply. I accept responsibility to pay for non-covered services or missed-appointment fees when applicable.

7. Confidentiality, Records, and Data Use

EFAP Provider maintains clinical records. Records are retained and disclosed in accordance with applicable privacy and health information laws. Aggregate, de-identified data may be used for program evaluation and quality improvement. Identifiable information will not be used for such purposes without additional written consent except as permitted by law.

8. Limitations of Liability, Governing Law, and Dispute Resolution

EFAP Provider's obligations are limited to provision of the services described herein. To the fullest extent permitted by law, the Provider is not liable for indirect, incidental, or consequential damages arising from participation in EFAP services. Any dispute arising under this Agreement shall be governed by the laws of the state or province in which services were provided, without regard to conflict-of-law principles.

9. Acknowledgment and Consent

By signing below I acknowledge I have read and understand the terms of this EFAP Agreement, the limits of confidentiality, and the services to be provided. I have had the opportunity to ask questions and receive answers regarding the program and my care.

Effective Date of this Agreement:

If signing on behalf of the patient, indicate relationship:

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