Eap Form Consent Provider

Aetna EAP Consent for Release of Information to Provider

I, ______________________________________, authorize Aetna Employee Assistance Program (EAP) and its affiliates to release information regarding _________________________________, to ____________________________, for the following purposes (please check): ❑ Talk

with

❑ Exchange ❑ Other

. written information with

.

(Explain reason for release and to whom it will be released):

In addition, Aetna’s Employee Assistance Program may communicate with appropriate clinical professionals regarding my care. I understand that my records are protected under Federal and State laws and cannot be disclosed or re-disclosed without a written consent, except as specifically stated by law. This authorization will expire ninety (90) days from the effective date. I may revoke this release at any time in writing.

EAP Participant Signature

Date

Witness Signature

Date

00.09.903.1 (6/04)