Tells Us About You

Your Mailing Address

Extended Care Mailing Address (if applicable)

How Can We Stay In Touch

I agree that all this information is correct. I also authorize The Lighthouse to contact me after discharge from treatment. I declare this consent is given freely and voluntarily, and I understand my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, as well as under HIPAA, 45 CFR Parts 160 and 164, and that no information may be disclosed by either party to any individual or agency unless by written consent of the patient. I also understand that this authorization may be revoked at any time in the future by written statement.

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