LA Valley Recovery Research Permission-incorrect

I agree to participate in progress monitoring research designed to improve the effectiveness of the treatment I receive during the time I am enrolled at Zinnia New Jersey Centers (“EHN/AHE”).  This monitoring will include information about potential mental health conditions, current and previous drug and alcohol use, and satisfaction with treatment.   I understand that this monitoring will be conducted by Vista Research Group, Inc. (“Vista”) using online surveys, and that all information I provide while I’m attending this treatment program will be immediately shared with the clinician(s) and/or the leadership of EHN/AHE so that it can be used to improve my treatment.  I agree that Vista may use email or text messaging to send me links to the surveys as well as a copy of this consent form.

I also agree that Vista may contact me periodically during the first 13 months after I leave EHN/AHE to determine how well I am doing.  Information I provide after treatment will be kept strictly confidential and will only be provided to the leadership of EHN/AHE after it has been de-identified and combined with that of many other patients.  The only exception to this would be if I specifically request that Vista notify EHN/AHE that I would like to be contacted by them to potentially consider going back into treatment.  This post-treatment outcomes research is designed to help EHN/AHE improve the treatment it provides to future clients.  As I’m not benefitting directly from this portion of the research, I will receive a small stipend in appreciation for my time. 

I give Vista permission to send me links to the surveys, gift cards, and a copy of this agreement by email or text.  I also give permission for gift cards and a copy of this agreement to be sent to me through the mail, and for Vista researchers to call me if they are unable to reach me via email or text.

I also agree that EHN/AHE may share with Vista my name, medical record number, birth date, gender, phone number(s), email address, the name and type of my health plan, the name(s) of my primary clinicians, and the dates and reasons why I am admitted, transferred and discharged from EHN/AHE’s program(s).

I understand that health information that may be used to identify me is protected under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and 45 C.F.R. Parts 160 and 164. The confidentiality of my health information may also be protected under 42 C.F.R. Part 2. I understand that my personally-identifiable health information and/or substance use disorder records cannot be disclosed without my written consent unless otherwise provided for by these federal regulations.

If I am under the age of 18, I understand that a parent or guardian will also be asked to agree to my participation, unless state law allows me to consent to treatment on my own.

I understand that permission to contact me expires 13 months after I have left EHN/AHE, and that I have the right to revoke this authorization at any time by emailing Finally, I understand that my enrollment at EHN/AHE is not contingent upon my involvement in this research.

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