Referral Form - Lighthouse

First Name *

Last Name *

Gender *

Male
Female

Date of Birth *

Phone *

Social Security Number *

Address

Lighthouse Client's Status *

City *

State*

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 *

Currently Incarcerated *

Needs Signed up for Medicaid *

Client is eligible for:

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 *

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.

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(614) 334-6903

Referral Form

Corporate Headquarters

888-805-1330

140 E Town Street, Suite 1450
Columbus, OH 43215

At Lighthouse, substance use disorder treatment is more than just recovery – it’s individuals living and thriving again. Our compassionate team of caregivers provides substance use disorder (SUD) and mental health treatment services that are evidence-based and effective. Most importantly, we remove the barriers standing between our clients and access to care in their community: helping them restore their dignity, wellness, and joy for life.

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