Maryland campral 2026

1. Click ‘Get Form’ to open the Maryland Campral Prior Authorization Form in the editor.
2. Begin by entering the patient's information, including the date, name, date of birth, and Maryland Medicaid number in the designated fields.
3. Next, fill out the prescriber’s information. Include the prescriber’s name, NPI number, phone number, and fax number.
4. Provide contact details for the person handling this request by filling in their name, phone number, and fax number.
5. Specify the medication details: enter the medication name (Campral), strength, quantity, refills needed, and directions for use.
6. Check all applicable boxes under Vivitrol and Campral criteria based on patient diagnosis and test results.
7. Describe the comprehensive management program that includes psychosocial support for the patient in the provided space.
8. Finally, ensure that the prescriber signs and dates the form before submitting it via fax to 866-440-9345.

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