Attestation of Person Completing This Referral Form
By submitting this referral, I certify and attest that I am the individual completing this referral form and that I have obtained the prospective client's authorization, consent, or other legally sufficient permission; the authorization, consent, or other legally sufficient permission of the client's parent, guardian, or legally authorized representative; or that I otherwise possess the legal authority necessary to provide the information contained in this referral to Healthy Avenues Medical Group for the purposes of evaluation, treatment, and care coordination.
I understand that submission of this referral does not authorize Healthy Avenues Medical Group to disclose protected health information, mental health records, substance use disorder records, psychotherapy notes, drug test results, or any other confidential information to me. I further understand that any such disclosure may require the client's separate written authorization and may be subject to HIPAA, Louisiana law, and 42 CFR Part 2.
I understand that a separate Release of Information (ROI) form may be required before Healthy Avenues Medical Group may disclose information to the referring party.
I certify that the information provided in this referral is accurate and complete to the best of my knowledge.
By selecting the acknowledgment box below and electronically submitting this referral, I acknowledge that I am the individual completing this referral form and that I have read and agree to the foregoing statements. I further acknowledge that my electronic submission constitutes my electronic signature and attestation.
