Below are our commonly requested forms. Feel free to print out the forms that you need.
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.
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 1-866-270-0219 ext. 1907.
The Emily Program
Medical Records Department
2265 Como Avenue
St Paul, MN 55108
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.
Intake Assessment Forms
Before you get started with services at The Emily Program, we have some paperwork for you to complete. These intake assessment forms include various documents that help us gather the important information we need from you to begin treatment. They also describe policies and operations that define the way The Emily Program provides care. The intake assessment forms vary depending on the state where you will be receiving treatment. Please visit our “Welcome Packet” page to find the forms appropriate for each location. Print and complete the documents according to the instructions. We ask that you bring your completed forms to your first appointment.
Coordinate with your Primary Care Provider (PCP)
To ensure the correct level of care for your needs, we recommend that you see a healthcare provider to get your medical history and physical exam with labs and an EKG.* Print the following form for your PCP to fill out, then bring it to your appointment at The Emily Program.
* Please note that this is required for Residential or Partial Hospitalization (PHP)/Intensive Day Treatment (IDP) admission.
We ask that clients at our Duluth and South Sound locations bring the following form to their PCP for medical follow-up appointments while they are in our PHP/IDP programming.