First Name * Last Name * Gender * Male Female Date of Birth * Phone * Social Security Number * Address Lighthouse Client's Status * City * State* Select State...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * Referral Details First Name * Last Name * Phone * Email * Client Needs (check all that apply) * Housing Substance Use Treatment Mental Health Treatment MAT Is the person a (check all that apply) Registered sex offender? Been convicted of arson? Have a history of violence? Currently Homeless * Yes No Currently Incarcerated * Yes No Needs Signed up for Medicaid * Yes No Client is eligible for: ATP SOR Mental Health Diagnosis * Drug of Choice * Last Date of Use * Existing Medications * Insurance * Yes No Primary Insurance Company * Primary Insurance ID/Group Number * Secondary Insurance Company * Secondary Insurance ID/Group Number * Policy Holder Name * Policy Holder Relationship * Subscriber’s DOB * Person making the referral * Return Phone/Email * Pregnancy Inquiry * I * authorize Lighthouse Behavioral Health Solutions to disclose *Describe how much and what kind of information may be disclosed, including an explicit description of any substance use disorder information to be disclosed; should be as limited as possible to *Name of entity with a treating provider relationship who will receive the information for the purpose of *Describe the purpose of the disclosure; i.e. admittance into program Release of information I understand that my substance use disorder records are protected under federal law, including the federal regulations governing the confidentiality of substance use disorder patient records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Parts 160 and164, and cannot be disclosed without my written consent unless otherwise provided for by the regulations. SUBMIT
