Get the free vivitrol patient assistance program

PLEASE REVIEW MEDICATION GUIDE WITH PATIENTS. VIV-001548 PAGE 2 If you have requested injection services for your patient Touchpoints will provide a selection of several injectors based on geographic proximity to your patient s address listed on the enrollment form from closest to farthest from such address. These injection providers are listed on the Provider Locator ll at www. .com. These options will be provided to you for your patient. We will also contact the selected injection services...

How to fill out patient assistance program for vivitrol form

How to fill out vivitrol enrollment form:

1. Start by gathering all necessary information, such as your personal details, medical history, and contact information.
2. Make sure you have a clear understanding of your eligibility criteria for vivitrol treatment. Consult with your healthcare provider if needed.
3. Begin filling out the form by providing your full name, date of birth, and social security number (if required).
4. Indicate your current address, phone number, and email address for communication purposes.
5. Specify your medical history including any previous substance abuse treatments, medications, and any other relevant health conditions.
6. Answer any questions related to your eligibility for vivitrol treatment, such as your previous use of opioids or alcohol, and your readiness for recovery.
7. Provide accurate information regarding your insurance coverage or any other payment options you will be utilizing to cover the cost of the treatment.
8. If required, provide the necessary signatures and dates to ensure the form is complete.
9. Double-check all the information provided to ensure its accuracy and completion before submitting the form.

Who needs vivitrol enrollment form:

1. Individuals who are seeking treatment for opioid or alcohol dependence may need to fill out the vivitrol enrollment form.
2. Those who have been prescribed vivitrol by their healthcare provider will need to complete the enrollment form to initiate the treatment process.
3. Individuals who meet the eligibility criteria for vivitrol treatment as determined by their healthcare provider will need to fill out the form to access the medication and associated support services.

People Also Ask about naltrexone patient assistance program

Does insurance pay for a Vivitrol shot?

99% of people with insurance are covered for VIVITROL ®, including most government and commercial plans.

What form does Vivitrol come in?

VIVITROL is an injectable suspension containing 380 mg of naltrexone in a microsphere formulation in a single-dose vial (3). VIVITROL is contraindicated in: Patients receiving opioid analgesics (4). Patients with current physiologic opioid dependence (4).

Do I need a prescription for VIVITROL?

VIVITROL is a prescription injectable medicine used to: treat alcohol dependence. You should stop drinking before starting VIVITROL.

Do you need a prescription for Vivitrol?

VIVITROL is a prescription injectable medicine used to: treat alcohol dependence. You should stop drinking before starting VIVITROL.

How do I get a prescription for Vivitrol?

You will need a prescription from a licensed health care provider to receive Vivitrol. Again, the medication is often administered through a drug or alcohol addiction treatment provider. However, some primary care doctors or internists also prescribe Vivitrol.

How do you qualify for VIVITROL?

Patients who currently meet DSM criteria for Alcohol or Opioid Dependence are eligible for Vivitrol therapy. These patients must have recently received detoxification from opioids and should be opioid-free for a minimum of 7 days.

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What is vivitrol patient assistance program?

The Vivitrol Patient Assistance Program is a program designed to provide financial assistance to individuals who are unable to afford the medication Vivitrol, which is used for the treatment of alcohol dependence and opioid dependence.

Who is required to file vivitrol patient assistance program?

Patients who have been prescribed Vivitrol and meet the eligibility criteria, which typically include financial need and lack of insurance coverage, are required to file for the Vivitrol Patient Assistance Program.

How to fill out vivitrol patient assistance program?

To fill out the Vivitrol Patient Assistance Program application, patients need to provide personal information, financial details, a copy of their prescription for Vivitrol, and any other required documentation as specified in the application form.

What is the purpose of vivitrol patient assistance program?

The purpose of the Vivitrol Patient Assistance Program is to ensure that individuals who are struggling with substance use disorders have access to necessary treatment without financial barriers.

What information must be reported on vivitrol patient assistance program?

Information that must be reported includes personal identification details, income level, insurance status, healthcare provider information, and the prescription information for Vivitrol.