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MEDICATION ASSISTED TREATMENTREQUEST FOR MONOTHERAPYSECTION 1: Identification of Member and Providers Last nameFirst nameMiddle initialAddress Phone number () Physician NameCityStateZIP Code release
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What is medication assisted treatment request?
Medication assisted treatment request is a formal request submitted by a patient or healthcare provider to receive treatment that combines medication with counseling and behavioral therapies to treat substance use disorders.
Who is required to file medication assisted treatment request?
Patients who are seeking medication assisted treatment for substance use disorders are required to file a medication assisted treatment request.
How to fill out medication assisted treatment request?
To fill out a medication assisted treatment request, patients must provide information about their medical history, substance use disorder, current medications, and contact information for their healthcare provider.
What is the purpose of medication assisted treatment request?
The purpose of a medication assisted treatment request is to request access to medications and therapies that can help a patient recover from substance use disorders and maintain their sobriety.
What information must be reported on medication assisted treatment request?
Information such as the patient's medical history, substance use disorder diagnosis, current medications, and contact information for their healthcare provider must be reported on a medication assisted treatment request.
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