Authorization & Confidentiality Notice:
IMPORTANT INFORMATION: By filling out and submitting this form, you are explicitly authorizing us to use the information provided to contact your insurance provider for the purpose of verifying eligibility, benefits, and coverage information for behavioral and mental health treatment services. Either a phone number or email is required in order to contact you to report our findings. In compliance with HIPPA regulations, we may only contact you regarding confidential health matters in ways that you explicitly authorize. When you provide your primary phone number or email, you are authorizing us to contact you via that method. For your privacy, utilize the method of contact that is least likely to infringe on your confidentiality or be reviewed by other parties. The information you provide will also be used by an Admissions Counselor to provide you with treatment options. Your information will not be shared with third parties or used for any other purpose than stated above. CONFIDENTIALITY NOTICE: The above submission form is protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. Pts. 160 & 164 and cannot be disclosed to anyone other than those outlined above without written consent unless otherwise provided for in the regulations. The Federal rules prohibit any further disclosure of this information unless written consent is obtained from the person to whom it pertains. The Federal rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient.