Vivitrol enrollment form 2026

1. Click ‘Get Form’ to open the vivitrol enrollment form in the editor.
2. 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.
3. Next, provide Injection Provider Information if applicable. Include the provider's name, address, and contact information.
4. 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.
5. Complete the Patient Diagnosis section by checking all applicable diagnoses related to alcohol or opioid dependence.
6. Finally, ensure that all required signatures are provided in the Provider Attestation and Patient Authorization sections before submitting.

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