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 Statement of Understanding 

 Statement of Understanding 

 Please fill out and submit this form for your EAP.

HIPAA

Compliance

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    It is important that you understand the confidential nature of your relationship with your Morneau Shepell counsellor. No one at Morneau Shepell will release your name or any information about you, your participation in counselling, or details of your counselling sessions to anyone outside of Morneau Shepell without your informed, voluntary, and written consent, except as outlined below:

    • When we are required by law to disclose what would otherwise be confidential information, such as when we believe you may pose a risk of serious injury to yourself or others, there is suspicion of child abuse as defined by applicable government legislation, or we are served with a properly executed court order.
    • If you occupy a safety sensitive position in your workplace your counsellor may be obliged to report drug and alcohol concerns to your company's Occupational Health provider in order to ensure employee and public safety.
    • Third party professional auditors may examine clinical booklets to evaluate the EFAP and validate the administrative information in this clinical booklet. These auditors will not be employees of Morneau Shepell or your organization. Your use of the EFAP will not be disclosed to your organization or any other party.

    Morneau Shepell is compliant with all Provincial, Federal and International privacy requirements, including HIPAA, Safe Harbour and a Privacy Officer. You may view our privacy policy online at http://www.morneaushepell.com/ca-en/privacy-policy, or request a hard copy by calling the EFAP number. If you have any concerns about our services, please contact the EFAP number and ask to speak with a Supervisor. We are available 24/7 to assist you.

    Program Eligibility: The EFAP counselling program offers assessment, counselling, and referrals, when necessary. It is your responsibility to determine whether your employer, insurer or government health plan covers the cost of services referred to outside the EFAP.

    Cancellation Policy: We require that all clients provide their counsellor with at least 24 hours’ notice of an appointment cancellation, otherwise the time might count against your available number of sessions.

    Counselling: The EFAP provides short term counselling. These services are most appropriate for people who have identified a specific concern and are prepared to work actively, with the help of a professional counsellor, toward implementing an action plan to resolve it. Because the specific number of hours needed may vary, the EFAP is designed to work with an average range of hours consistent with the short-term approach. The EFAP does not provide long term counselling. When this type of service appears appropriate, counsellors will refer you to public or private resources offering longer term or more specialized services. EFAP counsellors cannot advocate on your behalf in legal or work-related matters. If you require a copy of your clinical booklet, you will be charged a processing fee. Please contact your EFAP to make this request. Upon written request, any person participating in counselling may have access to the Clinical Booklet for the meetings at which they were present.

    Satisfaction Survey: You will be provided with a Satisfaction Survey. Please take the time to complete it.

    Your feedback is important to Morneau Shepell and helps us to continuously improve our services.

    Morneau Shepell reserves the right to use client information for statistical and research purposes regarding EFAP trends. All information collected will be entirely non-identifying and complete confidentiality will be maintained. Morneau Shepell will continue to provide services regardless of your participation in research.

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    I UNDERSTAND:

    • The Employee Assistance Program (EAP) is a confidential, voluntary service made available to me (and my family members).
    • EAP sessions are offered at no direct cost to me (or to my family members). The Affiliate has been approved to provide my assessment and problem resolution sessions with Morneau Shepell. If I choose to continue sessions with this Affiliate I will be responsible for all fees. Morneau Shepell cannot guarantee that this Affiliate will be covered under my insurance plan.
    • The EAP Affiliate is an independent contractor who provides services for Morneau Shepell.
    • The Affiliate cannot be involved with any legal, medical, or disability issue, including providing written documentation.
      If I need a referral to longer-term counseling or a specialized service, I will be responsible to pay for that service (including counseling provided by the Affiliate after sessions are completed). Insurance coverage under the Group Health Plan may defray some of the cost.
    • If I choose to contact the EAP, any information concerning the use of the EAP will not be given to anyone without my written consent. The only exception to this is if there is concern for my safety or the safety of others.
    • The EAP follows all State and Federal guidelines regarding confidentiality and complies with HIPAA standards pertaining to Protected Health Information (PHI) when applicable.
    • FOR SUPERVISORY REFERRALS ONLY – Morneau Shepell will confidentially inform the supervisor only if I contacted and decided to participate in the program. All other information requires a signed consent.
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    If client is a minor, please have guardian/parent sign
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