Referral Form | Lighthouse

Location *

Whitehall
Marysville
Reynoldsburg
Lima

First Name *

Last Name *

Gender *

Male
Female

Date of Birth *

Phone *

Social Security Number *

Address

City *

State*

Zip *

Client Needs (check all that apply) *

Housing
Substance Use Treatment
Mental Health Treatment

Currently Homeless *

Currently Incarcerated *

Needs Signed up for Medicaid *

Mental Health Diagnosis *

Drug of Choice *

Last Date of Use *

Existing Medications *

Insurance *

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 *

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

Consent

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.

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Referral Form

Began as a passion project born out of a family experience with addiction, Lighthouse Behavioral Health Solutions is changing addiction treatment and helping our clients realize the life they were intended to enjoy. We combine intensive outpatient treatment with recovery housing to create a community of people who are working through their recovery together, in a place full of compassion, energy, joy, and hope.

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