The purpose of the disclosure authorized in this consent it to: provide telephone recovery support. I understand that my alcohol and/or drug treatment records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPPA), 45 C.F.R. Pts. 160& 164 and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time. This consent expires automatically as follows:
1. I grant permission for a staff member or volunteer from Minnesota Recovery Connection (MRC) to call me at the above phone number and address to support me in my recovery.
2.Each time the MRC volunteer calls, he/she/they will be asking me how my recovery is progressing and if I am in need of additional support (i.e., meetings in area, recovery community centers, safe/sober housing, social events, and other resources).
3.At the time of the call, if I am in need of a referral to a treatment program or detox unit, I will be assisted in finding a program, if I so desire.
4. If at any time I decide not to take part in this program, I will call MRC at (612) 584- 4158 or tell the volunteer when he/she/they calls