Patient forms
LivingFree365 Program Forms
Paperwork for our Suboxone outpatient program. It is straightforward, and nobody at the front desk will treat you differently for carrying it.
What is in the packet
- Patient information and medical history
- Medication history, including current opioid use and any other prescriptions
- Treatment agreement for medication-assisted treatment
- Consent for Suboxone treatment and monitoring
- Confidentiality notice covering substance use disorder records, which carry protections beyond standard HIPAA
Confidentiality
Substance use disorder treatment records are protected under federal rules that are stricter than ordinary medical privacy. They are not released to employers, family or other providers without your written authorisation.
Be accurate, not tidy
The medication section is a safety document. Underreporting what you are taking makes your first dose less safe, not less embarrassing. Your physician has seen every version of this and is here to treat it.
Program fax
Referring providers and pharmacies can fax records to (502) 736-0140. Patients should call (502) 454-8800 rather than faxing personal documents.
What happens next
- 1Call (502) 454-8800 and say you are asking about LivingFree365.
- 2We send the packet and schedule your evaluation with a program physician.
- 3Bring the completed forms, photo ID and your insurance card to that appointment.
Prefer to talk? Call (502) 454-8800. We respond within one business day.
Request an appointment
Tell us how to reach you and what you're looking for. We'll confirm your insurance, answer your questions, and find a time that works. No long intake before you hear from a person.
- We respond within one business day.
- Most insurance accepted, including TRICARE and Medicare.
- In-office visits on Newburg Road, plus telehealth.