Voluntary Alumni Group Authorization & Waiver

Client Name

Client Date of Birth

Date of Admission:

Date of Discharge:

Recovery Centers of Montana offers a voluntary, non-clinical alumni Facebook group to provide post-treatment peer support. Participation is completely optional and will not affect your care, discharge planning, or access to services.

1. I Authorize the Following Disclosure:

Recovery Centers of Montana, including Admissions, Discharge, or designated Alumni Program Coordinators, may send me an invitation to the following group:

RCM Alumni - The RanchRCM Alumni - The LodgeTesla Roth-Director of Social Media Coordination

2. Nature of the Disclosure:

Participation may identify me as a former recipient of substance use disorder treatment. This is protected information under 42 CFR Part 2.

3. Purpose of Disclosure:

- This group is not a clinical service.

- It is not monitored by clinical staff.

- It is hosted on Facebook, which is not HIPAA- or 42 CFR Part 2-compliant.

4. Acknowledgments & Risks:

- My participation may disclose my treatment history.

- Other group members and Facebook are not bound by 42 CFR Part 2.

- RCM is not responsible for what others post in the group.

- Participation is voluntary and at my own discretion.

5. Expiration & Revocation:

This authorization remains in effect until I revoke it in writing or remove myself from the group. I may revoke it at any time by notifying staff in writing. If I revoke after joining the group, I understand it is my responsibility to remove myself from the Facebook group.

6. My Decision (Select One)

YES - I wish to remain in the Facebook Alumni Group. I understand that my continued participation may identify me as a former client of a substance use treatment program. I acknowledge that this group is hosted on Facebook, which is not HIPAA or 42 CFR Part 2 compliant. I am voluntarily waiving my right to confidentiality for the purposes of this alumni group and understand that RCM is responsible for disclosures made by other members. I understand I may revoke this consent at any time.NO - I do not wish to remain in the Facebook Alumni Group. I understand that I will be removed from the group, and this decision will not impact my care, discharge planning, or access to services now or in the future. I decline to authorize any further participation or disclosure through this group.

Client Signature:

Date:

Staff Witness (Print):

Staff Signature:

Date: