Release of Information Form

Release of Information (ROI)
Please remit the requested information to:

Office@RecoveryGlue.org

Requesting Provider:

RecoveryGlue.org

628 North Broadway (suite 302)

Lexington, KY 40588

(859) 309-0150

(859) 309-0151 (fax)
Patient information:
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Provider Information:
Provider Name*
Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number*
Please enter a valid phone number.
Information to be released: (Choose all that apply)*

DiagnosesTreatment PlanProgress NotesBiopsychosocialLab resultsTreatment Collaboration
Purpose of release
This authorization is valid for one year from the signed date*

MonthDayYear
Date
Patient Rights:

I understand that I have the right to revoke this authorization at any time by writing to the provider listed above.

I understand that the revocation will not apply to information that has already been released in response to this authorization.

I understand that I have the right to receive a copy of this authorization.

By signing this form, I understand that I am authorizing the release of my behavioral health information as specified above.
Signature

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Release of Information (ROI)