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Magellan Health Services

Magellan EAP Forms

Instructions

  • Use these forms when providing Employee Assistance Program (EAP) services.
  • Retain completed clinical forms in the client's chart.
  • Fill out forms completely and/or note why a section cannot be completed.
  • See the EAP provider handbook supplement for policies and procedures required for rendering services to EAP clients.

Important Note: EAP Registration Packets

Effective Aug. 1, 2014, Magellan no longer sends EAP Member Registration Packets by mail. Providers can view and print the packet documents securely online. Read more.

Initial Session Documentation

Generic Standard Statement of Understanding (PDF 124K) (English)

Spanish Generic Standard Statement of Understanding (PDF 124K)

Each client of adult age receiving services must sign a Statement of Understanding (SOU) indicating that they understand the nature of EAP services. For minors, a parent or legal guardian must sign the SOU, unless under applicable state law a minor can consent to treatment. A copy of the signed SOU is to be offered to the client. Use the company-specific SOU which is available in the online EAP Registration packet.

Client Information Form (PDF 115K)
This form is to be completed by the client.

Clinical Assessment (PDF 161K)
All clients age 12 and older are to be assessed for alcohol and other drug use, risk factors, and job/school impact. Include a risk assessment in the clinical assessment.

Counseling Plan (PDF 100K)
Initiate this form during the first session based on the clinical assessment.

Subsequent Sessions

Progress Notes (PDF 106K)
Progress Notes need to be completed only when there is more than one session.

Follow-up Summary (PDF 99K)
After completing the EAP services, clients must receive a follow-up contact within two to four weeks after the last session. When you make a referral for continued care beyond the EAP, the follow-up call must confirm that the client has followed through with the referral.

Reimbursement

To receive payment for EAP services rendered, you must complete the Employee Assistance Service Information (EASI) form.

Online EASI Form – Use the online application to conveniently and easily submit your EASI forms. Simply sign in with your secure username and password, and click on Submit an EASI Form on the left-hand menu (under My Claims).
EASI Form – hard copy for faxing or mailing (PDF 77K)
EASI Form Instructions (PDF 117K)
EAP Reimbursement Contact Information (PDF 57K)

You must submit the EASI form within 90 days of the end date indicated on the referral sheet, found in the EAP member registration packet for each specific case. Please refer to the EAP registration packet for the specific billing address.

EAP EFT Form (PDF 100K) – to request electronic funds transfer to your bank account

Auxiliary Forms (use as needed)

Substance Abuse/Chemical Dependency Assessment (PDF 148K)
If your assessment or the result of the chemical dependency (CD) screening indicates a possible CD issue, the Substance Abuse/Chemical Dependency Assessment form must be completed. This form documents that you have conducted a CD assessment.

Depression Screening (PDF 122K)
This optional tool can be used to assist in the assessment of client depression.

Case Management Notes (PDF 82K)
Case Management Notes are for tracking contacts with other providers (PCP, psychiatrists, other therapists, etc.) or other interested parties such as family members contacted for supplementary information.

Self-referral (PDF 60K)
This form must be completed if, after completing all EAP sessions, the member chooses to remain with the EAP provider for ongoing treatment.

See the EAP provider handbook supplement for policies and procedures required for rendering services to EAP members

If you have questions about any of the forms, call our national Provider Services Line at 1-800-788-4005.  

Management Referrals

Management Referral forms are specific forms required for legal and mandatory referrals. Please also refer to Appendix H (PDF) to review the Workplace Support Mandatory Referral Process and Staffing Guide for Management Referrals. Your Workplace Support Consultant will provide you with the Care Plan form specific for each case.

Statement of Understanding -- Mandatory (PDF)

Authorization to Use of Disclose Protected Health Information -- Mandatory (PDF)

Statement of Understanding -- Formal (PDF)

Authorization to Use or Disclose Protected Health Information -- Formal (PDF)

Guidelines to Fill Out Mandatory and Formal AUD and SOU (PDF)