Forms and Resources for Members, Managers and Providers

Our goal is to make it easy for our members to get help from the Employee and Member Assistance Programs. The documents on this page will help managers, members and providers gather and record essential information.

Click here to view our Notice of Privacy Practices.

For Managers

Management Referral Form

For Members

Statement of Understanding

For Mercy EAP Providers Regarding Billing

Mercy EAP Billing Sheet – Expiring 4/30/22
Mercy EAP Affliate Notification of EAP Billing Change and SAMPLE-Invoice Template – Effective 5/1/22
Mercy EAP Invoice Template, blank – Effective 5/1/22
Mercy EAP Invoice Template, with dropdowns/editable – Effective 5/1/22
Mercy EAP Invoice Template, fully electronic fillable – Effective 5/1/22

For Mercy EAP Providers

Patient Information & Demographic Sheet
Statement of Understanding
Audit Checklist
Case Staffing Form
Documentation Key
Intake Assessment
Authorization for Disclosure
Chemical Dependency, Medical, Psych History, Risk & Legal
Self-Referral Waiver