Employer Release Form

For the purpose of verifying compliance with BRIDGES Employee Assistance Program recommendations, I,

Enter Employee Name

hereby authorize and consent to the release of the following information by the EAP to the referring supervisor/manager,

Enter Supervisor/Manager Name

Whether the initial appointment was kept
Whether subsequent appointments were made and kept
Whether I have followed through with any recommendation made by the EAP Professional

I understand that my records are protected under the federal regulation governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, as well as the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:

I HAVE READ THIS RELEASE AND UNDERSTAND IT.

ANY QUESTIONS HAVE BEEN DISCUSSED WITH THE EMPLOYEE ASSISTANCE PROFESSIONAL.

This consent will remain in effect until the file is closed or one year after the date is signed.

Employee's signature

Date