EAPL etter Medical Release Form

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EAPL etter Medical Release Form Powered By Docstoc
					Date

MEMORANDUM

TO:           Name
              Title

FROM:         Name of Administrator
              Title

RE:           Employee Assistance Program


We have made an appointment for you with the Employee Assistance Program for an
evaluation.

Your appointment is with (name of doctor), on (day and date) at (time). His office is located
at (address).

You are required to sign and date the attached permission form for the release of medical
information to Mr. Berry in Human Resources. Please rest assured that any medical
information released will be held in the strictest confidence.

Please understand that we are concerned about your health and continued employment with
the District. We would like to make available to you any of the services that the district can
provide for your assistance.

Failure to attend this appointment could result in a disciplinary action against you.

rrs

Attachment – Medical Release Form

o: Leroy A. Berry – Deputy Superintendent
c: Joy A. Salamone – Director, Labor Relations

This is to confirm that a copy of the original of this document was provided to me on (Date)
by (Name and Title of Administrator).


My signature merely signifies receipt of this document and does not necessarily indicate
agreement with its contents.

___________________________________________                      __________________________
          Employee’s Signature                                            Date

                           EMPLOYEE ASSISTANCE PROGRAM (EAP)
                            SUPERVISORY REFERRAL ONLY

                             (please type or print legibly)



Employee Name: _________________________________ Social Security: _______________

Provider Name: ________________________________________________________________
                 (Psychiatrist, Psychologist or Counselor)




AUTHORIZATION TO RELEASE INFORMATION


If my employer formally referred me to the Employee Assistance Program (EAP), I hereby
authorize The Bradman Network to release information pertaining ONLY in accordance with
the following authorization.




My EAP counselor is authorized to release to my employer any information he/she deems
appropriate.


Employee’s Signature: ___________________________________ Date: ________________




                        Mr. Leroy A. Berry, Deputy Superintendent
                         School Board of Brevard County, Florida
                              2700 Judge Fran Jamieson Way
                                Viera, Florida 32940-6699

				
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posted:9/12/2012
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