VA Premier Sublocade Injection CIII Enrollment Form 2020-2025 free printable template
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Blockade (extended release)Phone: 8554274682 Fax: 8442327205Injection CII Enrollment Form (please use black ink)Specialty Pharmacy Enrollment Formulas detach before submitting to a pharmacy tear here.
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How to fill out VA Premier Sublocade Injection CIII Enrollment Form
01
Obtain the VA Premier Sublocade Injection CIII Enrollment Form from the appropriate sources.
02
Read the instructions carefully to understand the information required.
03
Fill out your personal details including your name, address, and contact information at the top of the form.
04
Provide your medical history relevant to the treatment, including any previous medications and treatments for substance use disorder.
05
Complete sections related to insurance information if applicable.
06
Include your healthcare provider's information, including their name, contact details, and facility.
07
Review the consent section and sign where indicated to authorize the treatment.
08
Double-check all information for accuracy before submitting.
09
Submit the completed form according to the provided instructions, either online, by mail, or in person.
Who needs VA Premier Sublocade Injection CIII Enrollment Form?
01
Individuals diagnosed with opioid use disorder who are seeking treatment.
02
Patients who have been recommended for Sublocade by their healthcare provider.
03
Individuals covered by VA Premier insurance seeking to utilize Sublocade treatment.
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What is VA Premier Sublocade Injection CIII Enrollment Form?
The VA Premier Sublocade Injection CIII Enrollment Form is a document used to enroll eligible patients for Sublocade, a medication used to treat opioid use disorder.
Who is required to file VA Premier Sublocade Injection CIII Enrollment Form?
Healthcare providers who intend to prescribe Sublocade to patients must complete and file the VA Premier Sublocade Injection CIII Enrollment Form.
How to fill out VA Premier Sublocade Injection CIII Enrollment Form?
To fill out the form, providers need to provide patient information, prescribing details, and any relevant medical history as specified on the form.
What is the purpose of VA Premier Sublocade Injection CIII Enrollment Form?
The purpose of the form is to formally enroll patients in the Sublocade treatment program and ensure compliance with regulatory requirements.
What information must be reported on VA Premier Sublocade Injection CIII Enrollment Form?
The form requires reporting patient demographics, treatment history, prescribing physician's details, and the rationale for Sublocade treatment.
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