Forms

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

Intake Packet (English Version) – Download PDF
Intake Packet (Spanish Version) – Download PDF

Printable Food Record Journals

Food Record Journal (full page) – Download PDF
Food Record Journal (half page) – Download PDF

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.

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

Release of Information – Download PDF
Financial Release of Information – Download PDF

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.

Insurance Verification Tool – Download PDF

Notice of Privacy Practices

Notice of Privacy Practices – Download PDF

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.

Grievance Process – Download PDF
Grievance Form – Download PDF

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By clicking “Send” below, you are indicating that you understand and agree to these terms regarding the use of your information:

The information you submit on this form will be used internally for the purposes of processing and responding to your request. It may be routed internally in order to find the most appropriate member of staff to handle your request and your contact information will only be used to respond to your inquiry if you indicate permission to do so.

In addition, the information submitted may become a part of the patient’s permanent chart or treatment record at The Emily Program upon their utilization of The Emily Program services, and this information may be used in the planning of treatment and care provided to the patient. At the time the patient utilizes The Emily Program services, The Emily Program’s Notice of Privacy Practices and other HIPAA and information privacy and security policies will apply to the information submitted on this form and to any other information that The Emily Program maintains about the patient and the care provided to the patient.