This referral form may contain protected health information. Please submit only the information necessary for referral review, appointment coordination, treatment coordination, insurance verfication, and related healthcare operations.

HIPAA & Referral Authorization Notice

By submitting this referral, I confirm that I am authorized to submit this to Alliance Behavioral Health Integrated, PLLC Clinic for referral review, appointment coordination, treatment coordination, insurance verification, documentation, and related healthcare operations.

I confirm that I have obtained the patient's consent, or the consent of the patient's parent, legal guardian, or authorized representative when applicable, to share the information provided in this referral form with Alliance Behavioral Health Integrated, PLLC Clinic.

I understand that this referral may include protected health information and that I am responsible for submitting only the minimum necessary information needed for referral review and care coordination.

I understand that submitting this referral does not guarantee acceptance into services or confirm an appointment. Alliance Behavioral Health Integrated, PLLC Clinic may contact the patient, parent/guardian, authorized representative, or referring party for additional information.

I confirm that the information submitted is accurate to the best of my knowledge.

Consent to Electronic Signature Collection & Electronic Record Storage

By competing and submitting this referral form, I agree to use an electronic signature for this referral submission I understand and agree that my electronic signature has the sale legal effect as a handwritten signature for the purpose of confirming this referral submission, authorizations,, and acknowledgements.

I consent to Alliance Behavioral Health Integrated, PLLC Clinic collecting, receiving, storing, and maintaining this referral form, my electronic signature, submission details, uploaded documents, and related referral information in electronic format.

I understand that the information submitted may include protected health information and will be used for referral review, appointment coordination, treatment coordination, insurance verification, documentation, and related healthcare operations.

I understand that electronic records may be stored in secure electronic systems used by Alliance Behavioral Health Integrated, PLLC Clinic and/or its authorized technology vendors. Alliance Behavioral Health Integrated, PLLC will take reasonable steps to protect electronic-protected healthcare information in accordance with applicable privacy and security requirements.

I understand that I may request a copy of this submitted referral or related records by contacting Alliance Behavioral Health Integrated, PLLC Clinic by phone at (623) 401-2882 or by emailing alliancebhiclinic@gmail.com.

I understand that submitting this referral electronically is voluntary, and that I may contact the office if I need an alternative method to submit referral information.