ST. JOSEPH MERCY HEALTH SYSTEM
Ann Arbor, Michigan 48106
EMPLOYEE ASSISTANCE PROGRAM
(734) 712-4096
CLIENT INFORMATION RELEASE AUTHORIZATION
I,
Client’s Name Soc. Sec. # Birthdate,
Authorize or
(Employee Assistance Program, Clinic or outside Agency/individual) its director, designee or records department, to release and exchange information contained in my records to the individual or organization listed below:
1.
Name and title of individual Telephone #
Name and Address of Agency/Program
2. Specific type of information to be disclosed:
Medical records of treatment for physical and/or emotional illness. Use of records regarding
alcohol or drug abuse treatment will comply with 42 Code of Federal Regulations, Part 2.
Results of Employee Assistance evaluation.
Other
3. The purpose and need for such disclosure:
Determine need for and/or type of treatment.
Monitor progress in treatment and job performance.
To make a referral for treatment or other services.
Other (specify)
4. This release may be revoked at any time. It shall be valid no longer than is reasonably necessary to accomplish the purpose for which it was given. No information will be disclosed to any third party without
your consent and signed release. No information will ever become part of your employment record without your specific request and signed release. This release becomes effective on (Date) and expires automatically in one year.
5. I understand that use of the Employee Assistance Program is voluntary and confidential. If, however, I
offer testimony or other evidence about this program in any type of litigation, then it may be necessary for
the program personnel to also testify or offer other evidence.
Client's Signature: ______Witnessed by: ______Requesting Counselor's Signature
Signature of
Parent of Guardian: ______Date Signed: ______
Date Signed: ______
Note: Persons or Agencies receiving information released by this form may not further release it without the formal written consent of the client. Shared/EAP/Forms/Release form-LD (10/30/08)