This application is secure. All submitted information is secured with bank-level encryption to ensure privacy and compliance with federal HIPAA regulations. By completing this referral application, you attest that you are either the client or are authorized by the client to submit personal/protected information to LifeCare Alliance on their behalf. Information collected in this referral application will become part of the client’s file at LifeCare Alliance.

By submitting this form, I hereby consent to the disclosure of the records to the purpose and extent stated. This authorization may be revoked by the client at any time to the extent that disclosure has not already occurred prior to the request for revocation. I understand that in order to revoke this authorization I must do so in writing. I understand that the information used or disclosed as a result of this authorization may be subject to re-disclosure by the person or entity receiving such information.