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Below are our commonly requested forms. Feel free to print out the forms that you need.

To fill out and submit forms online, download the With Me When App

Intake Documents

Printable Food Record Journals

Release of Medical/Health Information Forms

Release of Information Forms (ROIs) document your consent for The Emily Program to share information about you and your care. Two different ROIs are provided. The Release of Information Form allows us to communicate with your other healthcare providers, such as a primary care doctor or specialist, regarding treatment. It also gives your team at The Emily Program permission to communicate with family members and support people. The Financial Release of Information Form documents your consent for The Emily Program to share information regarding your treatment to your insurance provider.

We have also provided a Request to Revoke ROI Form to be used if you no longer wish to allow us to communicate with your other healthcare providers.

Once you have completed, signed, and dated the form, please mail or fax the form back to us. If you have questions, contact our Medical Records team at 1-888-364-5977 ext. 1907.

Mailing Address:
The Emily Program
Medical Records Department
2265 Como Avenue
St Paul, MN 55108

Fax: (844) 358-8782

Insurance Verification

It’s important that you understand the services that your insurance will cover. We’ve created the below tool to help guide you through the insurance verification process. This tool includes everything you will need to have ready for the phone call and every question to ask the insurance representative about your coverage.

Notice of Privacy Practices

Filing a Grievance

In order to guarantee clients a means to express their concerns, to ensure the integrity of service, and to preserve the positive therapeutic environment that The Emily Program (TEP) strives to provide, TEP has instituted a grievance policy and form. The Emily Program will work with clients, their parents or legal guardians and all other involved team members, outside agencies or providers, and staff to actively and objectively address client complaints or grievances (“grievances”) regarding any aspect of care. Please review the Grievance Policy below. Complete and submit the Grievance Form.

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