Solace Health Services respects the privacy and confidentiality of all individuals. Information submitted through this referral form may include personal and health-related information and will be used solely for the purpose of referral review, eligibility determination, care coordination, and service planning. Access to this information is limited to authorized personnel and handled in accordance with applicable federal and state privacy laws, including HIPAA, where applicable.

By signing below, I confirm that I have obtained the consent of the individual (or their legal guardian) to share the information provided in this referral with Solace Health Services for the purpose of service coordination and follow-up.