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Clinical Forms
EAP Forms
EAP Case Activity and Billing Form
(PDF)
Instructions
. (PDF)
Authorization for Use or Disclosure of Medical Information
(PDF)
Instructions
. (PDF)
Authorization for Use or Disclosure of Medical Information (Español)
(PDF)
Instructions
. (PDF)
Personal or Authorized Representative Authorization Form
(PDF)
Revocation of Authorization
(PDF)
Revocation of Authorization (Español)
(PDF)
Personal Representative Revocation of Authorization
(PDF)
Authorization for Use or Disclosure of Information for Formal or Mandatory Referrals to the EAP
(PDF)
Authorization for Use or Disclosure of Medical Information - DOT Referrals
(PDF)
EAP Participant Statement of Understanding
(PDF)
EAP Participant Statement of Understanding - Formal or Mandatory Referrals
(PDF)
