ME RCY EMPL OY EE A SSIS T ANCE PROGRA M
Authorization for Use and Disclosure of Private and Confidential Health Information THIS FORM WILL ALLOW MERCY EMPLOYEE ASSISTANCE PROGRAM (EAP) TO RELEASE THE PRIVATE HEALTH INFORMATION SPECIFIED BELOW TO THE PERSONS OR ENTITIES IDENTIFIED ON THIS FORM. Description of Private Health Information to be released——disclosure will not include diagnostic or clinical information: 1.
Attendance or Non-Attendance at EAP session(s).
2.
Suggestions, if any, resulting from the EAP assessment regarding workplace/supervisory strategy that may support improved work performance.
3.
Recommendation(s), if any, resulting from the EAP assessment. Information shall be limited to identifying the level of care (outpatient, partial hospitalization, inpatient or residential); type of referral resource (self help, support groups, medical evaluation, etc.) the name of the treating provider and/or facility if requested for purposes of ongoing follow-up.
4.
The estimated time frame necessary to complete the recommendation(s).
5.
The employee’s demonstrated Compliance or Non-Compliance with initial follow-through of the recommendation(s).
VERIFIC ATION Identification of person authorizing release (accuracy and completeness is necessary for this document to be valid): Date of Birth
Name of Participant Street Address
City
Participant’s Employer
State
Zip Code
Work Location
I authorize the persons or entities below to receive the information——disclosure will not include diagnostic or clinical information: Name of Contact Person(s)
Phone
Title/Department Street Address
City
State:
Zip Code
I understand that information used or disclosed based on this authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations. SIGNATURE I have read and understand the above information x
D a te
Relationship if person signing is other than participant THIS DOCUMENT WILL EXPIRE 60 DAYS FOLLOWING COMPLETION OF TREATMENT OR EDUCATION AS RECOMMENDED BY THE EAP PROVIDER
If the information disclosed to you relates to substance abuse treatment, in addition to HIPAA Privacy regulations, federal law protects these confidential records. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient to release substance abuse records. The Federal Rules restrict any use of the information to criminally investigate or prosecute any substance abuse patient. State laws may also protect the privacy of patients’ records, and may be more restrictive than applicable federal regulations.
Please return this completed form to:
MERCY EAP 903 Mineral Point Avenue, Janesville, WI 53548 Phone: 608.756.4681 • Fax: 608.755.4718
8704046 – N2 W/Y Rev 03/10
Employee Assistance Program (EAP) Informed Consent Page 1 of 1
Mercy EAP Management Support EAP services overview Mercy EAP provides services as a part of a worksite-based program designed to assist in the timely identification and resolution of productivity problems associated with personal stressors that may adversely affect employee job performance.
Management services – • • • •
Program orientation to managers/supervisors EAP consultation as needed during normal business hours (phone and/or on-site meetings) Management referrals to EAP for employee support with performance improvements needed Staff trainings available on managing stress, compassion fatigue, positive communication and other topics as requested • Critical Incident Response services accessible should a traumatic event occur • Additional work/life information and resources available online • Reports summarizing employee utilization and presenting issues on an aggregate basis
Employee services – • • • • • •
Confidential, appropriate, timely problem assessment services available as needed Short-term problem resolution/brief counseling Referrals for appropriate diagnosis, treatment and assistance Formation of links between workplace and community resources Follow-up services for employees as needed Each employee/household member eligible to receive up to 5 in-person sessions annually and available upon request
How to make a management referral to EAP At the first sign of a decline in an employee’s performance, early intervention can help them to get back on track. As a supportive manager, you can suggest they connect with EAP to avoid any performance issues (or disciplinary process). The Mercy Employee Assistance Program is a resource available to both managers and employees. EAP is totally confidential and can help with personal problems/stressors that may or may not yet be affecting an employee’s work performance. Self-referral — Your employee can contact Mercy EAP directly for supportive consultation. Supervisory referral — Based on an employee’s deteriorating or unsatisfactory job performance, you and/or HR can set up an EAP referral in one of two ways: • Informal referral: A suggestion is made to the employee; no EAP confirmation of an appointment is needed by the referring manager. • Formal referral: A request is strongly encouraged; EAP confirmation of dates of service is available with your employee’s signed release of information. (The process is detailed on the following pages.) Note: The employee’s decision to accept a referral to EAP and subsequent recommendations for support are voluntary, and are the personal responsibility of the employee.
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Performance indicators This information is offered to assist managers with performance-based language. It is critically important to avoid diagnosing the problem or making any comments as to the reasons for performance issues. Please refer your employee to EAP services to assess the situation and to provide support with any underlying stressors or extenuating circumstances.
Absenteeism
Communication
• • • • • •
• • •
• •
Unauthorized leave Excessive sick leave Monday absence, Friday absence Repeated absences of 2-3 days Leaving work early Peculiar or increasingly inprobable excuses for absences Excessive tardiness Frequent, unscheduled, short-term absences
Argumentative with coworkers and supervisors Less communicative than in the past Unclear or imprecise communication
Sporadic work patterns • •
Alternating periods of very high and very low productivity Quality of work produced differs from time to time
Difficulties in concentration/confusion
Initiative
• • • • •
• • •
• • • • • •
Job takes more time Work requires great effort Undependable Difficulty in recalling instructions clearly Increasing difficulty in handling complex assignments Difficulty in recalling own mistakes Forgetful Reduced awareness of what’s going on Frequent daydreaming Details often neglected Unable to keep current
Unwillingness to change work responsibilities Unwillingness to change ways of doing job Needs constant supervision or extra help
Interpersonal skills • • • • • • •
Constant complaints to associates and supervisors Overly critical of others Avoids making eye contact with others Makes unreliable or untrue statements Complaints from coworkers Wide swings in morale Overreacts to real or imagined criticism
Abnormal behavior • •
Coming or returning to work in an obviously abnormal condition Obviously bizarre or abnormal actions on the job
Presenteeism • • • •
Away from job more than job requires Frequent trips to break room or bathroom Long coffee breaks Physical illness on the job
High accident rate • • • •
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Accidents on the job Frequent trips to the medical department Damage to equipment Accidents off the job but affecting work performance
Lowered job efficiency • • • • • • • •
Missed deadlines Mistakes or bad decisions Inattention or impaired judgement Improbable excuses for poor job performance Lowered output Overly dependent on others Wastes materials Carelessness
The formal EAP management referral process There might be a time when you must follow a formal management referral process in order to document that the workplace has offered the employee a resource for assistance.
If the employee refuses your EAP referral, reinforce the organization’s expectations of compliance and satisfactory performance, and the consequences of failure to meet expectations.
The basis of a formal referral to EAP must be either (a) due to deterioration of performance that may appear to be impacted by a personal problem, or (b) in response to disclosure or positive evidence that a personal problem is the cause of inadequate performance.
If the employee accepts your EAP referral, give him a specific time frame for contacting EAP (2-3 business days) to schedule an appointment (within 7-10 business days). Explain the need for a signed release of information form to confirm completion of appointments (dates only). All other clinical information is totally confidential. Direct the employee to call (608) 756-4681 to access EAP support services.
By following the management referral process outlined below, you as a manager can offer support in helping to improve staff performance.
Step 5: Make the EAP referral Step 1: Call EAP for management consultation You will be able to brainstorm the concerns you have about the employee’s performance, and together develop a plan to address those concerns. This plan might involve HR and include an EAP management referral.
If your employee accepts EAP support, call (608) 756-4681 to confirm that an EAP referral has been made. Any relevant background information you can provide before the employee’s first appointment is extremely helpful.
Step 6: Forward any disciplinary paperwork Step 2: Gain support with the referral process Your EA consultant will explain the management referral process, including: • Employee access to EAP services • The release of information form • Compliance information, as well as any necessary follow-up process
Step 3: Schedule a meeting with your employee As part of the conversation with your employee, you will be able to discuss: • The employee’s recurrent performance problem • Your concerns using performance-based language (on previous page) • A plan for making improvements, and/or possible disciplinary action that might result if his performance still does not improve (a last-chance agreement can be helpful to clarify expectations) • That the employee has EAP support available for confidential, professional consultation for any personal problems or stressors that might be interfering with his work performance • Your performance expectations and your confidence in his ability to improve situation
Step 4: Recognize that the final decision to use EAP must be the employee’s. You and your HR rep play a critical role in emphasizing the availability of prepaid EAP sessions and encouraging access to EAP services to improve performance.
Please fax or send a copy of the Performance Improvement Plan or Corrective Action paperwork to EAP for background information and identifiying expectations: (608) 755-4718.
Step 7: After your referral Continue to review your performance expectations with the employee, and offer feedback on both successes and areas still needing improvement. Intervene immediately if further performance problems appear. Remember that your Mercy EA consultant is available for further status updates.
What your employee can expect When your employee accepts EAP support, he will call EAP at (608) 756-4681 to schedule an initial appointment. We will then: • Explain the prepaid EAP benefit (1-5 visits annually) • Reconfirm confidentiality. Only dates of service will be provided to person(s) named on the signed release of information to confirm employee’s compliance and motivation for making performance improvements At the initial appointment, the EA provider will assess the employee’s situation, help him problem solve, and make recommendations. The EA consultant might also connect the employee with any additional resources to help resolve performance issues.
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