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EVZIO Intake Form - AllCare Plus Pharmacy

EVZIO Intake Form - AllCare Plus Pharmacy 2025

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4.8 out of 5

293 votes

The document is an EVZIO Intake Form used for enrolling patients in a therapy program involving naloxone HCI injection. It collects patient and facility information, insurance details, clinical diagnosis codes related to opioid use, and prescription information for naloxone. The form also includes consent for the pharmacy to act on behalf of the patient regarding insurance prior authorization and emphasizes confidentiality in handling the transmitted information.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (293 Votes)

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