The information you provide through this referral form is classified as private data on individuals and will be used only to determine eligibility for services and to coordinate care and supports. Providing this information is voluntary; however, if you choose not to provide the requested information, we may be unable to determine your eligibility for services. The private information you submit may be shared with care coordinators, providers, and case managers as authorized by law, in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and all other applicable state and federal privacy laws.

 

Absolute Heath and Wellness is committed to protecting your privacy and keeping all client information confidential. All data collected through this form is securely stored and used solely for the purpose of delivering or coordinating services.

 

By submitting the form, you confirm that you have the legal authority to share this information and you consent to its use and disclosure for service coordination and eligibility determination, as permitted by applicable privacy laws.