ࡱ> kmjk "bjbj )@}}Xl4444444H 8 DP ,H: H " mL9999999$T= t?9u4]z9%44 k<:%%%$4 4 9%9%T %y%u744}9 | AU``LH H-8}9$R:0:E88@%@}9%HH4444  Authorization for Use and Disclosure of Private and Confidential Health Information This form will allow CIGNA Behavioral Health *, Inc. to release the private health information specified below to the persons or entities specified on this form. Description of Private Health Information to be released: Attendance or Non-Attendance at EAP session(s). Information will not include diagnostic or clinical disclosure Suggestions, if any, resulting from the EAP assessment regarding workplace/supervisory strategy that may support improved work performance. Information will not include diagnostic or clinical disclosure. Recommendation(s), if any, resulting from the EAP assessment. Information shall be limited to identifying the level of care: (outpatient, partial hospitalization, inpatient or residential), type of referral resource(s): (self-help, support groups, medical evaluation, etc.), the name of the treating provider and/or facility if requested for purposes of ongoing follow-up. Information will not include diagnostic or clinical disclosure The estimated time frame necessary to complete the recommendation(s). Information will not include diagnostic or clinical disclosure. The employees demonstrated compliance or non-compliance with initial follow-through of the recommendation(s). Information will not include diagnostic or clinical disclosure VERIFICATION Identification of person authorizing release: (Accuracy and completeness is needed for this document to be valid.) (Please complete all applicable items.) Name of Participant:  FORMTEXT       Street Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip Code:  FORMTEXT       Date of Birth: FORMTEXT       Participant s Social Security Number:  FORMTEXT       Participant s Employer Name: FORMTEXT       I authorize the persons or entities below to receive the information: Name of Contact:  FORMTEXT       Title and Department:  FORMTEXT       Street Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip code:  FORMTEXT       Phone number:  FORMTEXT       Purpose of this release of information: To confirm the employee s compliance with the process for formal management or continuation of employment referrals to the EAP and to assist in restoring optimal job performance. This document will expire 60 days following discharge from and/or completion of treatment or education as recommended by the EAP provider. Participant s Social Security Number:  FORMTEXT        I understand that information used or disclosed based on this authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations. I understand that if information on this form is not complete, CIGNA Behavioral Health will return the form to me, and this request will not be considered until CIGNA Behavioral Health has received all the required information. I understand that I may revoke this authorization by sending a written request to CIGNA Behavioral Health, EAP, 11095 Viking Drive, Suite 350 Eden Prairie, MN 55344 You can obtain a form to revoke the authorization by calling CIGNA Behavioral Health customer services at: 1.800.433.5768. Any revocation will not be effective for any actions CIGNA Behavioral Health may already have taken. SIGNATURE I have read and understand the above information: X Date: Relationship if person signing is other than Participant: Note that: If not already provided, we will require verification of the authority of a Personal Representative before this request will be considered complete. If this request is made by a Parent/Guardian, complete the following: Participant is a minor, years of age. If you are making this request on behalf of a minor child, we may require additional information before this request is considered complete. The provision of treatment, payment, enrollment or eligibility for benefits does not depend on whether you sign this authorization. It is recommended that you keep a signed copy of this authorization for your records, however a copy of this signed authorization can be provided upon your request. If the information disclosed to you relates to substance abuse treatment, in addition to HIPAA Privacy regulations, these confidential records are protected by federal law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient to release substance abuse records. The Federal Rules restrict any use of the information to criminally investigate or prosecute any substance abuse patient. State laws may also protect the privacy of patients records, and may be more restrictive than applicable federal regulations. Please Return This Completed Form To: CIGNA Behavioral Health Functional Area Name: Employee Assistance Program Functional Area Address: 11095 Viking Drive, Suite 350, Eden Prairie, MN 55344 Functional Area Facsimile: 952-956-7100 Staff Person s Name:  FORMTEXT       Staff Person s Telephone Number: 800-241-4057 x FORMTEXT       * CIGNA Behavioral Health refers to CIGNA Behavioral Health, Inc. and subsidiaries of CIGNA Behavioral Health, Inc., including CIGNA Behavioral Health of California, Inc. 11/11/2005ddb Management Referral 11/14/2005 HIPAA ROI PAGE  PAGE 2 CBH HIPAA AUTH2005 tuvmnR`Y   " $ 8 : < ʾʾʾʾʹۨxo^x j&B*OJQJUphB*OJQJphjB*OJQJUphB*CJOJQJph)jB*CJOJQJUmHnHphu\5CJOJQJ\ CJOJQJOJQJ5CJOJPJQJ\CJOJPJQJ5CJOJQJ CJOJQJ;CJOJQJ56@CJOJQJ jCJUCJvmn J  ]*d`^ 7$8$H$^ & F d,d,$-^-a$d""< F H J L l n  v z | Ӿ޵Ӿ޵Ӿ޵tcW5B*OJQJ\ph j5B*OJQJU\ph5B*CJOJQJ\ph j/(B*OJQJUph j'B*OJQJUph jC'B*OJQJUphB*OJQJph)jB*CJOJQJUmHnHphuB*CJOJQJphjB*OJQJUph%jB*OJQJUmHnHphu! ۷s`O`H CJOJQJ j)B*OJQJUph%jB*OJQJUmHnHphu j)B*OJQJUphB*OJQJphjB*OJQJUphB*CJOJQJph jCJOJQJUmHnHu5B*CJOJQJ\ph+j5B*OJQJU\mHnHphu j5B*OJQJU\ph&j(5B*OJQJU\ph &X `TX3flQ & F hv]Z^Zd l*d< l*dd,  ]*d` ES]*d`  &,.BDFPRX\|~~ǶǶǶzjU,OJQJUj+OJQJUji+OJQJUj*OJQJUj}*OJQJU jCJOJQJUmHnHu CJOJQJ5CJOJQJjOJQJUmHnHuj*OJQJUOJQJjOJQJU0 468BD (,.BDtdQ$j-B*CJOJQJUphjB*CJOJQJUph5B*CJOJQJ\ph5B*CJOJQJph5B*CJOJQJ]phB*CJOJQJphjA-OJQJU jCJOJQJUmHnHujOJQJUmHnHuj,OJQJUOJQJ5CJOJQJ\ CJOJQJjOJQJUDFPRTVXlTYZ[589=>hjknopƜ~ƜxbVSM 6OJQJ^J6CJOJQJ]^J*j6CJOJQJU]^JmHnHu 5OJQJ&j6CJOJQJU]mHnHu5CJOJQJ\ CJOJQJ jCJOJQJUmHnHu CJOJQJOJQJ 6CJ]6CJOJQJ]B*CJOJQJph)jB*CJOJQJUmHnHphujB*CJOJQJUphQZ8=>ijn x$1$If $ pdxa$U]UZx]Z (Zx]Z & F hv]  p0*e]e & F hv]nopj !!v""""~~~~~| l*d$a$$d<a$  p0*e]e]$$Ifl    )B*0    64 lapf j ! ! !!L!P!h!j!l!n!!!!!!!"""""""""""""""غ}vsvsvsvkvs0JmHnHu0J j0JUCJOJQJ56OJQJ5OJQJ\j5U\mHnHuj.5U\j5U\5\j5OJQJUmHnHuj-.5OJQJUj5OJQJU5CJ OJQJ CJOJQJ CJOJQJ 5OJQJ*"""""""""""""  p0*e]e  p0*h]hh]h&`#$ """"" CJOJQJOJQJ'0&PP/ =!"#$%&DdA%R  C .A?CBH 2colorb'&Z`RtI@=LG&Dn%Z`RtI@=LGPNG  IHDRc sRGB pHYs  ~%IDATx^xVpZ܊S` 2]`Cc 6\ۀᮥ8wW!{_i߶ yxxޛ$'hr=^~{lٵx#9E)Bx~x o -RĸѣW(^Q#vgO_v^{OBvG(E(c?xc/.u2%Iz׺ƀc xHnr]&8J8Jt/_㘎?@nyU1SG]jd SÀ [cefewzoh`g/yKƀ ٫W984byBB>;ػӀj"]r+0`t^b'bpŸR_>mx!ةSP!;G +l>r{`٬cF'ZԥؠFcG ^:/]ÃIbz%y_gz5@^ܨfmB/[ď]X۱2 0}u}aED1mٹLQKAT.k[ DCQ_X dvAKh8Y|tݪ~Dn16r%-+x[WG^+lpeC͚7]4\{8<75n81&-]0C6W&0TxŒ̭}h%\\i*U̕]㓂[Ov=q-jYVʙiVr[vr)4]Ac} "0![zY eHS4cJeћOGrd* $oV1 y24Mh À]+іBpH+ZNJ=g.rhnc_ԒH87#p9{ck:]n S|}*@g2E-t1 `$p ` VF}SgȵI@ѫ bM=ZǓz@XqKiI&f:#dȟ*ãR BJwDd,G+h [(3Y Mu9 ¢HzJKpҬc?;1+@ATt=.``_qcXҧc3~m!K.Vu.ýB ])g$a_)*D跟:xX1[!BqQI=̐5n?e xݹ)* ׉&I/ˈ.AD } o# ҽǏ{@HʛOcT ]0 ~-uK\*s[5 2~6N<]4pʵέ>||C%IbkY#$&)/{`c,Va'ا>00a]}qr|!{ۜ)0 lKUٖEV`TӦLaFv|B# ߸ Es&G D|fk\)U^g[ ).uyDXT/I$Ș,/:$ˑc̀#VH78-Q9=GuC5h ܱof|fo&.O6uR%Vڭ߹KpZʥU01o2 2#V&fSLbnDB9 sj.:+ܰ^TP€鋗.!Y\ !t?%K[`mW5`esq 9ٻl_ꓽ\? FԦ߈e\@CKp]`B Y' 雷3uljȵ/d Sq$t {_D 8#S 7Pjg-4ifY~GTXZ֬"W_f=uV,6hLE,椕[w.y ԠnjpqD\_3{b){DwM^9G#sˏs4!H00k XD'n%.շ`:I2} 1fʸln?ڑL1M'А< T3[ϲ5\u)eKPҧЅ-T၁˷*!4LM)n)40)=dG\^\5W6!la25SΨB`ygًebL֬/aW99_xXw}͢Q\Sƀ;pr XٮWon`Q tYv gq:%?]j}_@tLl?{ >* +=q@\sX,%sP;bAn1Qafa E#Ÿ]4+H{栿UFRջR)h~*%j ʇ_C6{)8 _h ݬۑ?Ҹ`n㈗"oV,0!k 8۪ܩ2wwWJs`q; FP+98"*zl.goH^c -%y"W̉ܙd9ks{/)qu˩ԼIvs?)ƀ%r {a4R[8phKDÜ%."SG9/a[2A:6ߐ8Roqqƀ8s_37 >EHE 9 9c^qaZPZ-@>;~caR^E+]):?W^ug=("0`)s/Vc 喐Nhp#vhz}]Sc hXh#B_h=l Sp6yM@Am ~Ak ,no u/!B#Hr L1`A8H! PCm 7;v~w'Aw.a ul^o 9fwȎsc!ۯaԔZ1 }4ڄ65A }Iʛ5\@qwIwb 9y=* a6A 5^eܖ/Xg︕y Qi9 ؊ AMh|5 t/7l|R^}zS-'H,zT!Wə%l:ҽ|[֫y7OaZ^Wɧ @= iȟ%gd\'J ء*Y" )s5Tq=[7 &T?J ٳ'N?M-'}$Ѭ.߂3w?tPm +Ƚ x~PGW{1$&;vL3r$t"ax]r R3zkY|̅"iɓChpь{N\!/j}X^Icc:<|KKo#]H"j˚$qYspֳ~1 |-Ahj |zOo-Ŝna@s˧zŀbN0[s=bOӧ}z;F}Yp4> |-^:|={N8 =<<&M_(P \p44riӦ] 3f,QD̘1>|n:XkժUaĉܲwމ'ʸ~BjԨvz \rKsm9:,^z-!E AxeEH_s>{'_"F=ztcbŊ꘳\xs ;e.\5jԴiӆ}{DWqƙ3g[8'4kUg˖@n9y%$Nk׮f3f́ʔ)Sl޽{_da9Az׽{Ç jmnmܸRS1`dɲ}v5ͬI&5%#Ξ= @6m9r|m[nmΝkPҨF+ݼ$֭[GQDa!YQ2;ƎoŊSC& $ud!dTT%eʔ)l~oS)Dgf^zaS#x:6jw0܂ :<ׯϞ=[̣Z*{ݻ v;vd9;wO+KnYGnL$@¦!vЬY3- N A[E l&s[J&/ռys6 191B,)BS;:w ,!]p $V%1s_hw(i_#ӧǰq00 `H`E kL[}WB^[IGț7/˗E`[7u9sD6AΜ9~f_!.)j߾}2^b? qcJ 3Z|'(K.mz1h磄SS #+ ؃q3k֬m 9Fs,O))}hѢX옋-jܸ 8o߾.W_}ExPhŊC4`0&RV? Q񇺳TPdɒ1JF#3q\T9b:ʦ?ui_ P$ +W)c&׾}{V OQ1VZ(Y\A7+ +hBmڴ)E o5YPD0j(~.+VDG+CL00Yqj،q Ï bp2Y<>}t f0Uϟ-^8ȡ/A;ECcHfv0~pٙ t'7n"Io͎%m &]5y. QW|J5lP5QS YTWʠAر'"E~ @]1: 6@% #Emx"=x T"8h~~~! /:Pk0ԩS!}ؠ &<-ԕ2$@\M*Pw GȃZk Cw{  axpD zb "0A.sc`LN~ګ;u bGMj4P_17~I:k,< n}¡$ub rZpURR־)y&C[@&ѪwKlr}{9SL]J9F`2e fE G7xGPD(T.c jJS*"gaK f@5zHʤk~ -a"% nG. l 7wCMQwvDXW1U$ RApФQ 2}to9~`N@aVGH`dfGP:uBa\$dCdC1@3i/ @ f(M@ ؀#T I"aBj "jIXFn  j̱c+ċ0pQU6:,-JQR}r]>^;bnah~Ŋ0ۿcOy0 3'@(HDiB:,uWYtf 4iARl` PE9^>k}PjNA aDfxb;`C o Cua,fC椱$,rRe*_\<$}0,F+'A Ȫķ+tQG^lAfK I+\xq kxS H'evZ_31>T'(XH&AV/A Ʀ?5SLxG ˦Q ـ1\*%a!1v,<^GTp!,A޸iPW j{i A+ʂBG0G3wQDX| ̶sN%M2E*+#4/اL XTުKѳ3A_U&A ǍÇf:)[bF< $}0p+K@[-{ZIENDB`vDText26vDText27vDText28vDText29vDText30vDText31vDText32vDText33vDText34vDText35vDText36vDText37vDText38vDText39vDText40vDText41vDText24vDText25 i@@@ Normal CJOJPJQJ_HmH sH tH J@J Heading 1$<d,@&^<5CJOJQJT@T Heading 2 $ (U<(@&]U5CJOJQJH@H Heading 3$<@&OJPJQJtH uL@L Heading 5$$@&a$5CJOJPJQJtH u<A@< Default Paragraph FontPP Content Tab 2  h: 0^`0CJFB@F Body Text  CJOJPJQJtH uROR Body text `#B*CJOJPJQJ_HmH sH tH BQ@"B Body Text 3CJOJPJQJtH uBP@2B Body Text 2 (5CJOJQJ,@B, Header  !, @R, Footer  !VC@bV Body Text Indent7$8$H$^CJOJPJQJ&)@q& Page Number@vmnQz{QZ   0 3 f l Q Z8=>ijnop5^v(0(@0@0v@0v@0v@0v 0v 0v 0v 0v 0v@0v@0v@0@0@0@00000000000000@0@0@000@0@0@0@ 0@ 0@0@ 0@0@000@0@000@0@0@0@000@0@0@0H@0@0@0@000@0@00@0@0@0@0@0@0@0 0+6WWWZ< Dp"" Qn"""=IOams lx~? K Q  sFFFFFFFFFFFFFFFFFF+26=?Z!!t8 @"(  HB  C DHB  C DHB  C DHB  C D HB  C DHB  C D#HB   C DHB   C D;HB   C DHB  C DHB  C D HB  C D HB @ C D  HB  C D HB  C D HB  C D HB  C DHB  C DHB  C DHB  C DHB  C D B S  ?{QRZ Z8j)t ) t ) ttu t S3*t  t )t=)t)t)t )tttgt &t8&tt1tkt)tText26Text27Text28Text29Text30Text31Text32Text33Text34Text35Text36Text37Text38Text39Text40Text41Text24Text25>bm@ t PtR  =Patl? R  s6=Patl= ? R  s3333333Sue Nordgaard-AmundsenuC:\Documents and Settings\scnord\Application Data\Microsoft\Word\AutoRecovery save of MGT REF-HIPAAROI-11-28-2005.asdSue Nordgaard-AmundsenvS:\EdenPrairie-MNEPRAI5\EAP\EAP Department\Manuals\EAC Forms\ROIs Management referrals\MGT REF-HIPAAROI-11-28-2005.docSue Nordgaard-AmundsenuC:\Documents and Settings\scnord\Application Data\Microsoft\Word\AutoRecovery save of MGT REF-HIPAAROI-11-28-2005.asdSue Nordgaard-AmundsenvS:\EdenPrairie-MNEPRAI5\EAP\EAP Department\Manuals\EAC Forms\ROIs Management referrals\MGT REF-HIPAAROI-11-28-2005.docrtwebsuC:\Documents and Settings\rtwebs\Application Data\Microsoft\Word\AutoRecovery save of MGT REF-HIPAAROI-11-28-2005.asdrtwebsnC:\Documents and Settings\rtwebs\Local Settings\Temporary Internet Files\OLK4E\MGT REF-HIPAAROI-11-28-2005.docSue Nordgaard-AmundsenuC:\Documents and Settings\scnord\Application Data\Microsoft\Word\AutoRecovery save of MGT REF-HIPAAROI-11-28-2005.asdSue Nordgaard-AmundsensS:\EdenPrairie-MNEPRAI5\EAP\EAP Department\Manuals\EAC Forms\ROIs Management referrals\MGT REF-HIPAAROI-2.17.06.docSue Nordgaard-AmundsensS:\EdenPrairie-MNEPRAI5\EAP\EAP Department\Manuals\EAC Forms\ROIs Management referrals\MGT REF-HIPAAROI-2.17.06.docJeanette M OlsonIC:\Documents and Settings\jmstai\My Documents\CBH Website Updates\ROI.doc rmD.\nx 5DG kW R% \j7b |Y@fDPzdU^&Uxp#88^8`o()^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.88^8`o()^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L. hh^h`OJQJo(88^8`o()^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.88^8`o()^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L.hhh^h`OJPJQJ^Jo(o 88^8`OJQJo(o ^`OJ QJ o(   ^ `OJQJo(   ^ `OJQJo(o xx^x`OJ QJ o( HH^H`OJQJo( ^`OJQJo(o ^`OJ QJ o(h^`.hpp^p`.h@ L@ ^@ `L.h^`.h^`.hL^`L.h^`.hPP^P`.h L ^ `L.^`o()^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.88^8`o()^`. L ^ `L.  ^ `.xx^x`.HLH^H`L.^`.^`.L^`L. GrmY@fDkW\nx \j7UxR%dU^ :I        d;        Ա{        <        b                          z܈        jno"@tp P@P P PPPP,@P PD@Unknown G: Times New Roman5Symbol3& : ArialA& Arial Narrow3z TimeseC Futura CondensedCourier NewoCB Futura CondensedBoldCourier NewSMonotype SortsSymbol?5 z Courier New;Wingdings"1hfJfJffd )1#0d2q4C:\Documents and Settings\msand1\Desktop\ROIForm.dot$Authorization for Use and DisclosureMauricio SandovalJeanette M OlsonOh+'0 ,8 T ` l x%Authorization for Use and Disclosureft uthMauricio SandovalUsaur ROIForm.dotJeanette M OlsonUs2anMicrosoft Word 9.0s@@[tm@JG`L@JG`Lfd՜.+,0 hp  CIGNAz) 2 %Authorization for Use and Disclosure Title  "#$%&'()*+,-./012345678:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXY[\]^_`acdefghilRoot Entry Fd``LnData !/1Table9@WordDocument)@SummaryInformation(ZDocumentSummaryInformation8bCompObjjObjectPoold``Ld``L  FMicrosoft Word Document MSWordDocWord.Document.89q