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MEDICATION ASSISTED TREATMENT REQUEST FOR /NALOXONE 24MG PER DAY Complete ENTIRE form and Fax to: 8669407328 SECTION 1: Identification of Client and Providers Last name First name Middle initial Address
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What is medication assisted treatment request?
Medication assisted treatment request is a formal application filed to seek approval for medication assisted treatment for substance use disorders.
Who is required to file medication assisted treatment request?
Healthcare providers or treatment facilities looking to provide medication assisted treatment are required to file the medication assisted treatment request.
How to fill out medication assisted treatment request?
To fill out the medication assisted treatment request, healthcare providers or treatment facilities must provide information about the patient, the proposed treatment plan, and any relevant medical history.
What is the purpose of medication assisted treatment request?
The purpose of medication assisted treatment request is to obtain approval for using medication as part of the treatment plan for substance use disorders.
What information must be reported on medication assisted treatment request?
The medication assisted treatment request must include information about the patient's medical history, the proposed treatment plan, and any supporting documentation.
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