Informed Consent for Employee Assistance Program Services

In-person and Telehealth

Employee Assistance Program Services

The Employee Assistance Program (EAP) is an employer-sponsored benefit provided by ComPsych Corporation and offered to employees and eligible family members. EAP services may include assessment and brief counseling to clarify issues, identify choices, develop an action plan, and for follow-up and support. The EAP does not provide diagnosis, treatment, court-related services or ongoing counseling. You have the right to ask questions and be informed regarding the scope and limitation of the EAP services you are participating in and you also have the right to stop using EAP services at any time.

Confidentiality

ComPsych and the EAP counselor will maintain confidential records of your contact with the EAP and the services provided. ComPsych and the EAP counselor may collect and maintain Protected Health Information (PHI) under the Health Insurance and Portability and Accountability Act (HIPAA). ComPsych and the EAP counselor will not share any of your confidential information, including PHI, without your written or verbal consent, except as otherwise permitted by federal and state confidentiality laws. ComPsych and the EAP counselor may use or disclose PHI without your authorization for purposes of: (1) treatment and to coordinate care; (2) to comply with applicable law, including to report suspected child abuse or neglect or suspected abuse or neglect of an elder or vulnerable person; and (3) to prevent or lessen a serious and imminent threat to your health or safety or the health and safety of the public.

The ComPsych HIPAA Privacy Notice is available below. This Notice provides information regarding your rights and ComPsych’s duties to protect your PHI.

Mandatory Referrals/Management Referral

If you are receiving EAP services based on a management referral, you will be asked to give your consent to advise the referral source whether you are participating in the EAP and cooperating with the EAP plan. What is discussed in the EAP session will not be discussed with the referral source, unless your consent permits disclosure.

Cost

EAP Services are provided at no direct cost to employees and eligible family members. However, if a recommendation or referral is made for services outside of, or beyond the EAP, the employee and/or eligible family member will be responsible for any costs associated with such services. Your health insurance may provide coverage for services outside of the EAP services, and employees are responsible for determining insurance eligibility and the cost of these services.

Telehealth Services

In the event you are receiving EAP Services by audio, visual or data communications, the following is applicable and you agree that:

  • You understand that you are engaging in telehealth services in order to ensure your service needs are met in a timely manner. You understand that you will not be in the same room as your EAP counselor and will meet with your EAP counselor by phone or video.
  • Your EAP counselor explained how technology will be used to connect you with services and you have the necessary technology to engage in telehealth services. You understand that your sessions could be interrupted due to technical difficulties, and that you or your EAP counselor may discontinue the session and the services if the technology available is not adequate to provide the services via telehealth.
  • Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with telehealth services, however, when using technology, there is always the risk of a breach of information outside of the control of ComPsych or your EAP counselor. All existing privacy protections under applicable law apply to information disclosed during telehealth sessions.
  • You understand that in the event of a medical or psychiatric emergency during your telehealth session with your EAP counselor, you will be expected to go to the nearest hospital for services. You also understand that your EAP counselor may elect to contact emergency services if you become incapacitated or otherwise need assistance in obtaining emergency care.

Client Satisfaction

Your satisfaction with EAP services is important to us. With your consent, you will be emailed a short survey related to your experience with EAP services.

ComPsych Corporation Notice of Privacy Practices (Effective August 1, 2022)

This Notice Describes How Medical Information About You May Be Used and Disclosed and How You Can Get Access to This Information. Please Review it Carefully.

ComPsych Corporation is committed to maintaining the confidentiality of all information it receives. ComPsych is required by law to maintain the privacy of Protected Health Information (“PHI”) and to provide all individuals with notice of ComPsych’s legal duties and privacy practices with respect to PHI. ComPsych and your EAP Counselor (hereinafter collectively referred to as “ComPsych”) will use your PHI for the purposes of managing your care. The purpose of this notice is to inform you of how ComPsych may use and disclose PHI. This notice also describes your patient rights, and informs you of how to contact ComPsych. ComPsych will abide by the terms set forth in this Notice.

Uses and Disclosure of PHI without your authorization

Your PHI will be used by ComPsych to ensure that you receive the services covered by your benefit plan. ComPsych may use or disclose PHI as described below without your authorization for purposes of treatment, payment or health care operations. The following are examples of how information is used and disclosed for such purposes:

  • Your PHI may be used and disclosed by ComPsych, your EAP Counselor and others who are involved in your care for purposes of providing, coordinating or managing your care and any related services. This includes coordination or management of your health care with a third party, consultation with other health care providers or referral to another provider for health care treatment.
  • Outside auditors and other third parties may gather various information from ComPsych to track the quality of services ComPsych provides.
  • The following are other circumstances where ComPsych may disclose PHI without your authorization:
    1) To comply with applicable law; 2) for specified public health activities and purposes; 3) for health oversight activities; 4) in judicial or administrative proceedings in response to a legal order or other lawful process; 5) to the police or other law enforcement officials as required by law or in compliance with a court order or other process authorized by law; 6) to prevent or lessen a serious and imminent threat to the health or safety of an individual or the public; 7) to units of the government with special functions, such as the U.S. military or the U.S. Department of State; or 8) as necessary to comply with workers’ compensation laws.

Uses and Disclosure of PHI that require your authorization

ComPsych’s use or disclosure of your PHI other than those exceptions listed above as permitted in this Notice of Privacy Practices will be made only with your written authorization.

  • More specifically ComPsych must obtain your authorization for: 1) uses and disclosures of psychotherapy notes with limited exceptions; 2) use and disclosure of your PHI made for marketing purposes; 3) prior to making a communication of your PHI for which ComPsych may receive payment; and 4) certain PHI that is “highly confidential information” such as information about mental health and developmental disabilities, alcohol or drug abuse, genetic testing and HIV/AIDS.
  • If you do provide authorization for use or disclosure of PHI listed above or any other disclosure not specifically permitted in this Notice of Privacy Practices, you have the right to revoke such authorization at any time to stop any future uses and/or disclosures. Any revocation will not apply to disclosures made prior to the revocation.

Your Patient Rights

  • You have the right to request to inspect and copy your PHI that ComPsych maintains. Under certain circumstances, ComPsych may deny your request. ComPsych may charge a fee for all costs associated with your request.
  • You have the right to request that ComPsych amend your PHI that ComPsych maintains. Under certain circumstances, ComPsych may deny your request. Your request must include a reason supporting the requested amendment.
  • You have the right to request an accounting of disclosures. This accounting will not include disclosures that were made for purposes of treatment, payment or health care operations or disclosures made pursuant to your Authorization or disclosures to you. Your request must state the specific time period. An accounting is not available for disclosures made prior to April 14, 2003. The first accounting you request in any 12 month period shall be provided at no cost. For any additional requests, ComPsych may charge a fee.
  • You have the right to request that ComPsych restrict its use or disclosure of your PHI when carrying out treatment, payments or health care operations. It is important to understand that ComPsych is not required to agree to your request. All requests must specifically state what information you want to limit and to whom the limitation applies.
  • You have the right to request that ComPsych communicate with you in a specific manner.
  • You have the right to restrict certain disclosures of PHI to a health plan where you pay out of pocket in full for the healthcare item or service.
  • You have the right to be notified following a breach of your unsecured PHI.
  • You have the right to receive a paper copy of this Notice.

Contact

If you need further information about matters covered by this Notice, all requests must be sent to the privacy official through electronic or written communication. Please document your request and send it to ComPsych via email: [email protected] or mailed to: ComPsych Corporation, 455 N. Cityfront Plaza Drive, 13th Floor, Chicago, IL 60611, Attn: Privacy Official. For urgent matters, you may call 312-660-1076 in addition to submitting your documented request.

If you believe that your privacy rights have been violated, you may contact ComPsych directly or the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against for reporting a violation of your privacy rights. ComPsych reserves the right to change its privacy practices at any time and any such change shall apply to all PHI ComPsych maintains, including information created or received by ComPsych prior to issuing a new Notice. If ComPsych materially changes its privacy practices, this Notice shall be amended and disseminated to all individuals.

Si require que este documento sea traducido, comuniquese al numero 1-888-664-4225. Updated 02/2023