Helix / Amethyst Recovery Solutions Release of Information (ROI)

I understand that my records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and the Health Insurance Portability and Accountability Act (HIPAA) of 1996, 4 CFR Parts 160 & 164, Subparts A & E and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand the information to be released may include records related to behavioral and/or mental health care and/or alcohol and drug abuse treatment. This authorization may be revoked at any time except to the extent that AMETHYST RECOVERY SOLUTIONS has already taken action in reliance on it. AMETHYST RECOVERY SOLUTIONS will not condition treatment on whether or not I sign the authorization. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal law. It is understood that where federal laws or state laws relating to the court system apply, they should take precedence over any expiration or revocation expressed.

Amethyst Recovery Solutions

Client Information

I hereby authorize AMETHYST RECOVERY SOLUTIONS:

To/From

Company Organization: Helix Health and Housing Services

Relationship: Treatment Provider

Address: 1035 Broadway Ave | Minneapolis, MN 55411

Phone Number: +1-651-300-0465