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Library of Forms

Our affiliate providers can access any forms necessary for managing a client case on this Web page. Just click on any of the links listed below to access and download the selected form.

Empathia, Inc

08 Authorization for Disclosure of Protected Health Information please call for a copy

08 Empathia Clinical Reimbursement Form please call for a copy

Trainer Application

W-9 Form

Affiliate Manual

Manual Acknowledgement Form

Affiliate Application

Affiliate Application (Fill out online and print)

08 Trauma Response Services Form please call for a copy

Empathia Pacific

Provider Clinical Services Packet

Instructions for Service

Instructions and Forms for Provider Dispute Resolution Request

EAP Clinical Assessment

Progress Notes

EAP Case Closure Form

Provider Reimbursement

Statement of Understanding & Consent to Participate

Statement of Understanding & Consent to Participate - Spanish

Notice of Privacy Practices

Notice of Privacy Practices - Spanish

Authorization For Disclosure of Confidential Information

Authorization For Disclosure of Confidential Information - Spanish

Michigan Alcohol Screening Test

Drug Abuse Screening Test

Freedom of Choice Affidavit

Freedom of Choice Affidavit - Spanish

W-9 Form

Grievance Form

Grievance Form - Spanish