01. Edit your vivitrol2gether enrollment form online
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Vivitrol enrollment form 2026
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- Click ‘Get Form’ to open the vivitrol enrollment form in the editor.
- Begin by filling out the Prescriber Information section. Enter the Prescriber Name, Tax ID, State License, NPI, and contact details. Indicate whether your office will be administering VIVITROL.
- Next, provide Injection Provider Information if applicable. Include the provider's name, address, and contact information.
- In the Patient Information section, enter the patient's full name, date of birth, gender, and insurance details. Ensure to attach a copy of both sides of the patient’s insurance card.
- Complete the Patient Diagnosis section by checking all applicable diagnoses related to alcohol or opioid dependence.
- Finally, ensure that all required signatures are provided in the Provider Attestation and Patient Authorization sections before submitting.
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vivitrol enrollment form
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