Our Forms

The following files are PDF files. If you do not have Adobe Acrobat Reader on your computer, you can download the program here.

Program Statement & Consent to Disclosure 

Main Line Health Notice of Privacy Practices (HIPAA)

Authorization Form

Release of Information to Employer

Provider Application and Profile

Group Provider Profile

Instructions for Completion of FIRSTCALL Forms

Program Statement and Consent to Disclosure
Please read this carefully. You must write-in the maximum number of sessions for which a client is eligible. (The intake coordinators will have given you this information.) This form has been devised to:

1. Obtain the client’s signed consent for you to send/transmit confidential information to us and
2. Inform the client that no confidentiality exists between you, as an independent contractor with the FIRSTCALL Employee Assistance Program, and the FIRSTCALL EAP administration. This will eliminate the need for a separate authorization to transmit/mail clinical records to us.

Be sure to return the Program Statement and Consent to Disclosure along with the Case Summary Report and, if needed, any signed Release of Information to Employer forms (used for management referrals).

Authorization

This form is mailed to you at the time of referral and is to be completed after you have had your final EAP contact with the client. It serves as a record of service as well as your invoice to us. Please be sure to complete all sections of the form. Incomplete forms will be returned to you for completion and will result in delayed payment to you.

Only document appointments that have been completed, whether they are face-to-face sessions or pre-authorized telephone sessions; do not include broken or cancelled appointments. Note that payment will only be made for telephone contacts with clients whose employer has contracted for a telephone-only program. Telephone contacts are not reimbursed for clients who have a face-to-face program model.

Under Assessed Problems, please mark only one problem for primary assessed problem and, if applicable, one for secondary assessed problem. All cases must have a "primary assessed problem".

Only complete information in the field "referral destination" if you have selected "Referral Accepted" under "discharge status".
Under the field "referral destination", you may mark as many elements as apply. If, however, you have referred a client to his/her HMO for care, the only additional elements that you can select are "social/legal/financial" or "other".