ROI

This form authorizes Troopers to communicate and share relevant health-related information with the medical, psychiatric, behavioral-health, or case-management provider named below. The purpose of this disclosure is to support comprehensive care coordination, treatment planning, and transitional-living support in accordance with New Mexico Administrative Code 7.32.8 and 7.20.12, as part of your participation in Troopers programs. Troopers is committed to protecting your privacy while ensuring that you receive the care, structure, and services necessary to support your recovery, safety, and housing stability.

Participant Information

Your name, date of birth, and contact number will be collected at intake solely to verify your identity and to coordinate services with other care providers or agencies actively involved in your support. All personal data are maintained securely under HIPAA and 42 CFR Part 2 standards.

Provider Information

Troopers may exchange limited but necessary information with your identified healthcare, mental-health, or case-management provider. Shared information may include your identifying details, appointment attendance, medication verification, or progress summaries to promote continuity of care and program compliance. Information will be released only to those individuals or agencies specifically authorized under this agreement.

Collection of Information

As part of your participation in Troopers programming, we may collect and maintain documentation relevant to your care and residence. This includes your full name, date of birth, phone number, emergency contact, referral forms, intake assessments, case-management notes, appointment records, medication lists, and program participation logs. All information is used strictly to coordinate services, maintain safety, and ensure the delivery of quality care within state regulatory requirements for transitional and sober-living environments.

Purpose of Disclosure and Information Sharing

Troopers may share your personal information with authorized individuals or organizations directly connected to your care and supervision. These may include:

  • Licensed medical, psychiatric, or mental-health providers

  • Substance-use treatment programs or peer-support specialists

  • Social workers, case managers, or probation/parole officers

  • Housing or community-support partners involved in your stability plan

Such disclosures may be required to coordinate medication management, treatment appointments, legal compliance, housing placement, benefit assistance, or discharge planning. No information will be shared for marketing, fundraising, or any purpose unrelated to your treatment and well-being.

Scope of Information That May Be Shared

With your written consent, Troopers may disclose the following information as relevant to your care and program participation:

  • Identifying information and contact details

  • Medical or behavioral-health diagnoses and treatment plans

  • Medication lists and prescribing-provider information

  • History of substance-use treatment or relapse prevention plans

  • Case-management or progress notes

  • Attendance and participation in required groups or activities

  • Legal supervision or compliance status (if applicable)

All shared information will be limited to the minimum necessary for coordination of care and will be transmitted securely, in compliance with HIPAA and 42 CFR Part 2.

Duration and Revocation of Authorization

This authorization remains valid for one (1) year from the date of signing unless revoked sooner in writing. You may revoke this authorization at any time by submitting a written request to Troopers Administration. Troopers will cease sharing information upon receipt of your revocation; however, any information disclosed before revocation cannot be withdrawn.

Voluntary Consent and Your Rights

Signing this form is voluntary. Refusal to sign will not automatically disqualify you from Troopers housing or support programs, but it may limit our ability to coordinate medical care, verify legal compliance, or secure certain community resources on your behalf. You may revoke consent at any time in writing. Upon request, Troopers will provide a list of all individuals or agencies with whom your information has been shared under this authorization.

Limits of Confidentiality

While Troopers makes every reasonable effort to protect your privacy, the following legal exceptions apply under New Mexico law:

  • If there is reason to believe you are at risk of seriously harming yourself or someone else.

  • If there is suspected abuse, neglect, or exploitation of a child, elder, or vulnerable adult.

  • If Troopers is required to comply with a valid court order, subpoena, or mandated-reporting statute.

Only the minimum necessary information will be disclosed, and efforts will be made to preserve your dignity and confidentiality at all times.

Acknowledgment and Authorization Statement

By visiting our website or anything related to the Troopers domain, you confirm that you have read and understand this Confidentiality & Consent to Share Information Notice. You understand why your information may be collected and how it may be used or shared. You understand your right to revoke consent at any time, and that this form does not authorize the release of information to any person or organization not listed. You also understand that all shared information will remain protected under applicable state and federal privacy laws, including HIPAA and, when applicable, 42 CFR Part 2.