Phone: (800) 932-3918-2026

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

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