New Recovery Services GPRA Form

Version 1.1
Created 01/24/2023

1. Name of RECOVERY COACH filling out this form: *This question is required.

2. Email address:
(example: acb@mail.com) *This question is required. Confirmation and a PDF copy of this form will be sent to the email below. Email may contain confidential information and PHI, please check the email address to be sure it is being sent to a secure address. This question requires a valid email address.

3. Which Recovery Center are you reporting on: *This question is required.

4. Hospital - (optional) If reporting on RCED Program

New Recovery Services GPRA Form

Administrative Section