Housing Coordination Authorization

Organizations Authorized to Exchange Information

___________________________________________________

Amethyst Behavioral Healthcare
2300 Myrtle Ave, Suite 120
St. Paul, MN 55114
Phone: (651) 661-6665

and

All In Recovery
2499 Rice Street #120,
Roseville, MN
Fax: 651-677-2332
https://allinrecovery.care/welcome

___________________________________________________

This authorization permits the exchange of information between Amethyst Behavioral Healthcare ("ABH") and All In Recovery ("the Organization").

I authorize ABH and the Organization to exchange information for the purpose of coordinating my care, treatment, referrals, recovery support services, housing-related services, case management, service planning, continuity of care, discharge planning, insurance and benefit coordination, appointment scheduling, eligibility verification, and other services necessary to support my recovery, wellbeing, and service needs.

I specifically authorize ABH to provide my Comprehensive Assessment to the Organization for these purposes.

I understand that information exchanged under this authorization may include, but is not limited to:

• Comprehensive Assessment
• Assessments and evaluations
• Admission and discharge information
• Treatment recommendations and treatment plans
• Attendance and participation information
• Progress notes and service documentation
• Case management records
• Recovery support records
• Housing-related information and documentation
• Referral information
• Appointment scheduling information
• Medication-related information, as permitted by law
• Insurance, eligibility, and benefit information
• Laboratory and toxicology testing results, as permitted by law
• Medical information
• Mental health information
• Substance use disorder treatment information
• Any other information reasonably necessary for the coordination and provision of services

I understand that information exchanged under this authorization may include information protected under federal confidentiality regulations, including 42 CFR Part 2, as well as applicable state and federal privacy laws.

I understand that signing this authorization is voluntary, that I may refuse to sign it, that I may revoke it at any time by providing written notice to either ABH or the Organization except to the extent that action has already been taken in reliance upon it, and that I am entitled to receive a copy of this authorization.

This authorization will expire one (1) year from the date of signature unless revoked earlier in writing.

Authorization to Release Assessment Documents

I authorize ABH to obtain, receive, and re-release my Comprehensive Assessment and Professional Statement of Need to the Organization for the purpose of determining eligibility for services, coordinating care, facilitating referrals, and supporting treatment and recovery planning. I understand that this authorization applies only to these documents and constitutes a single consent for this specific disclosure. I understand that the Organization may not re-disclose these documents to any other person or organization without my separate written consent, unless otherwise permitted or required by law, and must maintain the confidentiality of this information in accordance with applicable federal and state privacy laws.

Organizations Authorized to Exchange Information

___________________________________________________

Amethyst Behavioral Healthcare
2300 Myrtle Ave, Suite 120
St. Paul, MN 55114
Phone: (651) 661-6665

and

Change Place
Email:
info@change.place

Phone:
612-248-3000

Website:
https://change.place/

___________________________________________________

This authorization permits the exchange of information between Amethyst Behavioral Healthcare ("ABH") and Change Place ("the Organization").

I authorize ABH and the Organization to exchange information for the purpose of coordinating my care, treatment, referrals, recovery support services, housing-related services, case management, service planning, continuity of care, discharge planning, insurance and benefit coordination, appointment scheduling, eligibility verification, and other services necessary to support my recovery, wellbeing, and service needs.

I specifically authorize ABH to provide my Comprehensive Assessment to the Organization for these purposes.

I understand that information exchanged under this authorization may include, but is not limited to:

• Comprehensive Assessment
• Assessments and evaluations
• Admission and discharge information
• Treatment recommendations and treatment plans
• Attendance and participation information
• Progress notes and service documentation
• Case management records
• Recovery support records
• Housing-related information and documentation
• Referral information
• Appointment scheduling information
• Medication-related information, as permitted by law
• Insurance, eligibility, and benefit information
• Laboratory and toxicology testing results, as permitted by law
• Medical information
• Mental health information
• Substance use disorder treatment information
• Any other information reasonably necessary for the coordination and provision of services

I understand that information exchanged under this authorization may include information protected under federal confidentiality regulations, including 42 CFR Part 2, as well as applicable state and federal privacy laws.

I understand that signing this authorization is voluntary, that I may refuse to sign it, that I may revoke it at any time by providing written notice to either ABH or the Organization except to the extent that action has already been taken in reliance upon it, and that I am entitled to receive a copy of this authorization.

This authorization will expire one (1) year from the date of signature unless revoked earlier in writing.

Authorization to Release Assessment Documents

I authorize ABH to obtain, receive, and re-release my Comprehensive Assessment and Professional Statement of Need to the Organization for the purpose of determining eligibility for services, coordinating care, facilitating referrals, and supporting treatment and recovery planning. I understand that this authorization applies only to these documents and constitutes a single consent for this specific disclosure. I understand that the Organization may not re-disclose these documents to any other person or organization without my separate written consent, unless otherwise permitted or required by law, and must maintain the confidentiality of this information in accordance with applicable federal and state privacy laws.

Organizations Authorized to Exchange Information

___________________________________________________

Amethyst Behavioral Healthcare
2300 Myrtle Ave, Suite 120
St. Paul, MN 55114
Phone: (651) 661-6665

and

Stronger Sober Living
Email:
strongersoberhouse@gmail.com

Phone:
651.243.2343

Fax:
651-262-0388

Website:
https://www.strongersoberhouse.com/?utm_source=chatgpt.com

___________________________________________________

This authorization permits the exchange of information between Amethyst Behavioral Healthcare ("ABH") and Stronger Sober Living ("the Organization").

I authorize ABH and the Organization to exchange information for the purpose of coordinating my care, treatment, referrals, recovery support services, housing-related services, case management, service planning, continuity of care, discharge planning, insurance and benefit coordination, appointment scheduling, eligibility verification, and other services necessary to support my recovery, wellbeing, and service needs.

I specifically authorize ABH to provide my Comprehensive Assessment to the Organization for these purposes.

I understand that information exchanged under this authorization may include, but is not limited to:

• Comprehensive Assessment
• Assessments and evaluations
• Admission and discharge information
• Treatment recommendations and treatment plans
• Attendance and participation information
• Progress notes and service documentation
• Case management records
• Recovery support records
• Housing-related information and documentation
• Referral information
• Appointment scheduling information
• Medication-related information, as permitted by law
• Insurance, eligibility, and benefit information
• Laboratory and toxicology testing results, as permitted by law
• Medical information
• Mental health information
• Substance use disorder treatment information
• Any other information reasonably necessary for the coordination and provision of services

I understand that information exchanged under this authorization may include information protected under federal confidentiality regulations, including 42 CFR Part 2, as well as applicable state and federal privacy laws.

I understand that signing this authorization is voluntary, that I may refuse to sign it, that I may revoke it at any time by providing written notice to either ABH or the Organization except to the extent that action has already been taken in reliance upon it, and that I am entitled to receive a copy of this authorization.

This authorization will expire one (1) year from the date of signature unless revoked earlier in writing.

Authorization to Release Assessment Documents

I authorize ABH to obtain, receive, and re-release my Comprehensive Assessment and Professional Statement of Need to the Organization for the purpose of determining eligibility for services, coordinating care, facilitating referrals, and supporting treatment and recovery planning. I understand that this authorization applies only to these documents and constitutes a single consent for this specific disclosure. I understand that the Organization may not re-disclose these documents to any other person or organization without my separate written consent, unless otherwise permitted or required by law, and must maintain the confidentiality of this information in accordance with applicable federal and state privacy laws.

Organizations Authorized to Exchange Information

___________________________________________________

Amethyst Behavioral Healthcare
2300 Myrtle Ave, Suite 120
St. Paul, MN 55114
Phone: (651) 661-6665

and

Pyramid Place

Phone: 347-325-4268

Address: 770 University Avenue West, St. Paul, MN

___________________________________________________

This authorization permits the exchange of information between Amethyst Behavioral Healthcare ("ABH") and Pyramid Place ("the Organization").

I authorize ABH and the Organization to exchange information for the purpose of coordinating my care, treatment, referrals, recovery support services, housing-related services, case management, service planning, continuity of care, discharge planning, insurance and benefit coordination, appointment scheduling, eligibility verification, and other services necessary to support my recovery, wellbeing, and service needs.

I specifically authorize ABH to provide my Comprehensive Assessment to the Organization for these purposes.

I understand that information exchanged under this authorization may include, but is not limited to:

• Comprehensive Assessment
• Assessments and evaluations
• Admission and discharge information
• Treatment recommendations and treatment plans
• Attendance and participation information
• Progress notes and service documentation
• Case management records
• Recovery support records
• Housing-related information and documentation
• Referral information
• Appointment scheduling information
• Medication-related information, as permitted by law
• Insurance, eligibility, and benefit information
• Laboratory and toxicology testing results, as permitted by law
• Medical information
• Mental health information
• Substance use disorder treatment information
• Any other information reasonably necessary for the coordination and provision of services

I understand that information exchanged under this authorization may include information protected under federal confidentiality regulations, including 42 CFR Part 2, as well as applicable state and federal privacy laws.

I understand that signing this authorization is voluntary, that I may refuse to sign it, that I may revoke it at any time by providing written notice to either ABH or the Organization except to the extent that action has already been taken in reliance upon it, and that I am entitled to receive a copy of this authorization.

This authorization will expire one (1) year from the date of signature unless revoked earlier in writing.

Authorization to Release Assessment Documents

I authorize ABH to obtain, receive, and re-release my Comprehensive Assessment and Professional Statement of Need to the Organization for the purpose of determining eligibility for services, coordinating care, facilitating referrals, and supporting treatment and recovery planning. I understand that this authorization applies only to these documents and constitutes a single consent for this specific disclosure. I understand that the Organization may not re-disclose these documents to any other person or organization without my separate written consent, unless otherwise permitted or required by law, and must maintain the confidentiality of this information in accordance with applicable federal and state privacy laws.

Organizations Authorized to Exchange Information

___________________________________________________

Amethyst Behavioral Healthcare
2300 Myrtle Ave, Suite 120
St. Paul, MN 55114
Phone: (651) 661-6665

and

New Heights Sober Homes

3980 5th St NE

Columbia Heights, MN 55421

Phone: 763-205-2487

Fax: 763-205-4761

Email: newheightssoberhouse@gmail.com

___________________________________________________

This authorization permits the exchange of information between Amethyst Behavioral Healthcare ("ABH") and New Heights Sober Homes ("the Organization").

I authorize ABH and the Organization to exchange information for the purpose of coordinating my care, treatment, referrals, recovery support services, housing-related services, case management, service planning, continuity of care, discharge planning, insurance and benefit coordination, appointment scheduling, eligibility verification, and other services necessary to support my recovery, wellbeing, and service needs.

I specifically authorize ABH to provide my Comprehensive Assessment to the Organization for these purposes.

I understand that information exchanged under this authorization may include, but is not limited to:

• Comprehensive Assessment
• Assessments and evaluations
• Admission and discharge information
• Treatment recommendations and treatment plans
• Attendance and participation information
• Progress notes and service documentation
• Case management records
• Recovery support records
• Housing-related information and documentation
• Referral information
• Appointment scheduling information
• Medication-related information, as permitted by law
• Insurance, eligibility, and benefit information
• Laboratory and toxicology testing results, as permitted by law
• Medical information
• Mental health information
• Substance use disorder treatment information
• Any other information reasonably necessary for the coordination and provision of services

I understand that information exchanged under this authorization may include information protected under federal confidentiality regulations, including 42 CFR Part 2, as well as applicable state and federal privacy laws.

I understand that signing this authorization is voluntary, that I may refuse to sign it, that I may revoke it at any time by providing written notice to either ABH or the Organization except to the extent that action has already been taken in reliance upon it, and that I am entitled to receive a copy of this authorization.

This authorization will expire one (1) year from the date of signature unless revoked earlier in writing.

Authorization to Release Assessment Documents

I authorize ABH to obtain, receive, and re-release my Comprehensive Assessment and Professional Statement of Need to the Organization for the purpose of determining eligibility for services, coordinating care, facilitating referrals, and supporting treatment and recovery planning. I understand that this authorization applies only to these documents and constitutes a single consent for this specific disclosure. I understand that the Organization may not re-disclose these documents to any other person or organization without my separate written consent, unless otherwise permitted or required by law, and must maintain the confidentiality of this information in accordance with applicable federal and state privacy laws.

Organizations Authorized to Exchange Information

___________________________________________________

Amethyst Behavioral Healthcare
2300 Myrtle Ave, Suite 120
St. Paul, MN 55114
Phone: (651) 661-6665

and

Underdog Recovery Homes
651.391.2412
https://underdogrecoveryhomes.com/ 

___________________________________________________

This authorization permits the exchange of information between Amethyst Behavioral Healthcare ("ABH") and Stronger Sober Living ("the Organization").

I authorize ABH and the Organization to exchange information for the purpose of coordinating my care, treatment, referrals, recovery support services, housing-related services, case management, service planning, continuity of care, discharge planning, insurance and benefit coordination, appointment scheduling, eligibility verification, and other services necessary to support my recovery, wellbeing, and service needs.

I specifically authorize ABH to provide my Comprehensive Assessment to the Organization for these purposes.

I understand that information exchanged under this authorization may include, but is not limited to:

• Comprehensive Assessment
• Assessments and evaluations
• Admission and discharge information
• Treatment recommendations and treatment plans
• Attendance and participation information
• Progress notes and service documentation
• Case management records
• Recovery support records
• Housing-related information and documentation
• Referral information
• Appointment scheduling information
• Medication-related information, as permitted by law
• Insurance, eligibility, and benefit information
• Laboratory and toxicology testing results, as permitted by law
• Medical information
• Mental health information
• Substance use disorder treatment information
• Any other information reasonably necessary for the coordination and provision of services

I understand that information exchanged under this authorization may include information protected under federal confidentiality regulations, including 42 CFR Part 2, as well as applicable state and federal privacy laws.

I understand that signing this authorization is voluntary, that I may refuse to sign it, that I may revoke it at any time by providing written notice to either ABH or the Organization except to the extent that action has already been taken in reliance upon it, and that I am entitled to receive a copy of this authorization.

This authorization will expire one (1) year from the date of signature unless revoked earlier in writing.

Authorization to Release Assessment Documents

I authorize ABH to obtain, receive, and re-release my Comprehensive Assessment and Professional Statement of Need to the Organization for the purpose of determining eligibility for services, coordinating care, facilitating referrals, and supporting treatment and recovery planning. I understand that this authorization applies only to these documents and constitutes a single consent for this specific disclosure. I understand that the Organization may not re-disclose these documents to any other person or organization without my separate written consent, unless otherwise permitted or required by law, and must maintain the confidentiality of this information in accordance with applicable federal and state privacy laws.