Sign up for services with Voices of Hope

I give permission for my information and data to be securely stored in an electronic database accessible only to Voices of Hope – Lexington, Inc. employees and trained volunteers. I authorize a representative from Voices of Hope – Lexington, Inc. to contact me at the phone number I provided to offer support with my recovery. During these calls, they may ask about my recovery progress and whether I need any additional support. If I choose to stop participating in this service at any time, I will notify Voices of Hope – Lexington, Inc. by email at info@voicesofhopelex.org or inform the representative during a call. Any information I share with the representative will remain confidential, except in situations where disclosure is required by law, such as threats of harm to self or others, or reports of child abuse or neglect. I understand that my substance use disorder records are protected under federal law, including the confidentiality rules outlined in 42 C.F.R. Part 2 and the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 and 164. My records cannot be shared without my written consent, except as permitted by these regulations. I understand that I may revoke this consent at any time by submitting a written request to Voices of Hope – Lexington, Inc., except to the extent that action has already been taken based on my prior consent. I understand that I may be denied services if I refuse to authorize information sharing for purposes related to treatment, payment, or healthcare operations, if allowed by state law. I will not be denied services for refusing to authorize disclosure for other purposes. I understand that this consent is valid for one year from the date of my signature unless otherwise stated, and that I must complete a new form annually to continue receiving services.

Voices of Hope – Lexington, Inc. will not discriminate against anyone applying for or receiving assistance or services based on race, religion, color, national origin, sex, sexual orientation, gender identity, disability, age political beliefs, or reprise or retaliate for prior civil rights activity or any other protected class identified in federal, state, or local laws. Voices of Hope – Lexington, Inc. agrees to comply with the provisions of the Kentucky Civil Rights Act, the Americans with Disabilities Act ADA) of 1990 as Amended, Section 1557 of the Patient Protection and affordable Care Act, Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, as applicable, and all other applicable federal, state, and local regulations relating to prohibiting discrimination.