ARS/ABH Info Exchange ROI

Client Information

Name

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Organizations Authorized to Exchange Information

This authorization permits the exchange of information between the following organizations:

Amethyst Recovery Solutions
700 Raymond Ave, Suite 100
St. Paul, MN 55114
Phone: (651) 661-5322
Email: intakes@arsmn.org

and

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

I authorize the exchange of information between Amethyst Recovery Solutions and Amethyst Behavioral Healthcare for the purpose of coordinating my care, treatment, recovery support services, housing-related services, case management, referrals, and other services necessary to support my recovery and wellbeing.

I understand that this authorization includes the exchange of information reasonably necessary to coordinate my care and services, including assessments, treatment recommendations, treatment plans, attendance information, progress information, referrals, housing-related information, case management records, discharge planning information, insurance and benefit information, laboratory testing results, medication-related information as permitted by law, and other information necessary for coordination of services.

I understand that information protected under federal confidentiality regulations governing substance use disorder treatment records (42 CFR Part 2), as well as applicable state and federal privacy laws, may be exchanged under this authorization as permitted by law.

I understand that the purpose of this exchange of information is to support continuity of care, treatment planning, service coordination, referrals, recovery support, housing support, insurance coordination, appointment scheduling, discharge planning, and other activities necessary to provide effective services.

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

Client Signature

Client Signature Date

Date

Staff/Witness Signature

Staff/Witness Signature Date

Date

AUTHORIZATION FOR EXCHANGE OF INFORMATION