This form is intended for use by referral sources who have recently transferred an individual to SpiritLife Inc. Please complete the fields below to submit the member’s current authorization information. This helps our team ensure accurate billing, timely service verification, and proper coordination of care. This form is for professional use only (e.g., case managers, providers, or MCO representatives). It is not intended for general inquiries or client self-referrals. Confidentiality Notice: This form is HIPAA-compliant and intended solely for the secure transmission of protected health information (PHI) between professionals. All information submitted will remain confidential and used exclusively for treatment, payment, and healthcare operations as permitted under federal law. If you have questions while completing this form, please contact the SpiritLife Admissions team at (724) 402-3238 now!