Doctor form 2026

1. Click ‘Get Form’ to open the doctor form in the editor.
2. Begin by entering your Patient Name, Medicaid Number, Date of Birth, and Phone Number in the designated fields. Ensure all information is accurate for proper identification.
3. Read through the agreement carefully. Each section outlines important responsibilities regarding the use of opioid dependence treatment drugs. Make sure you understand each point before proceeding.
4. In the signature section, print your name clearly and sign to acknowledge that you have read and agree to the terms outlined in the document.
5. The prescriber will also need to fill out their printed name and signature. Ensure this is completed before submitting.
6. Once all fields are filled out correctly, save your changes and choose to either fax or mail it as instructed at the top of the form.

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