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Phone: (800) 932-3918-2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the patient’s information. Fill in the date, name, date of birth, and Maryland Medicaid number in the designated fields.
- Next, provide the prescriber’s information. Enter the prescriber’s name, NPI number, phone number, and fax number accurately.
- Identify a contact person for this request by filling in their name and phone/fax numbers.
- Specify the medication details including medication name, strength, quantity, and refills required.
- In the directions for use section, clearly outline how the medication should be administered.
- Check all applicable boxes under Vivitrol or Campral criteria based on the patient's condition and history.
- Finally, ensure that the prescriber signs and dates the form before submitting it via fax to (866) 440-9345.
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