Vivitrol2Gether Patient Enrollment Form

Patient Enrollment Forms

Vivitrol2Gether Patient Enrollment Form. If you elect to work directly over pharmacies, were provide the resources you needing, with vivitrol my members available to answer your questions Patient will transition to provider below for future injections.

Patient Enrollment Forms
Patient Enrollment Forms

Web there are adenine variety of resources available to help support yourself and your patients along my recovery tour including filling vivitrol prescriptions. Web (first) date of birth (middle initial) (last) gender male female address city state zip code mobile phone # phone instructions (best number) home phone # email address instruct patient to list alternate designated contact(s) on page 2. Web if you are considering vivitrol ®, call vivitrol2gether sm to learn about our patient support services. Participation is free of charge. Web patient enrollment form complete all fields to avoid processing delays. Get help finding a provider who can answer questions about vivitrol and get you started, and find out how to transition from one setting of care to another. Web an enrollment form for offices that wish to work with a vivitrol2gether ® dedicated case manager to send prescriptions to pharmacies on behalf of their patients. If you elect to work directly over pharmacies, were provide the resources you needing, with vivitrol my members available to answer your questions Web there are a variety of sources available to help technical you and choose patients along my recovery journey included filling vivitrol specifications. Transition of care coordinationfax completed form to:

Another option if vivitrol is covered through the medical benefit is for the healthcare provider to buy units of vivitrol from a specialty distributor and bill the patient’s insurance directly when it is administered. Transition of care coordination patient needs vivitrol by (date) / preferred pharmacy (optional) / phone # special shipping instructions please select one patient will receive future injections at this site. Participation is free of charge. Web link to vivitrol2gether ® enrollment form on previous page. Another option if vivitrol is covered through the medical benefit is for the healthcare provider to buy units of vivitrol from a specialty distributor and bill the patient’s insurance directly when it is administered. Web (first) date of birth (middle initial) (last) gender male female address city state zip code mobile phone # phone instructions (best number) home phone # email address instruct patient to list alternate designated contact(s) on page 2. Web an enrollment form for offices that wish to work with a vivitrol2gether ® dedicated case manager to send prescriptions to pharmacies on behalf of their patients. Fill vivitrol enrollment form, edit online. Transition of care coordinationfax completed form to: Patient diagnosis —(a list of possible codes can be found on page 5, section 15) Web if you are considering vivitrol ®, call vivitrol2gether sm to learn about our patient support services.