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For Healthcare ProfessionalsVIVITROL ( for 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Patient Information. Fill in the patient's name, date of birth, and phone number. Indicate whether the patient is new to therapy or continuing therapy.
- In the Medical Information section, select the appropriate diagnosis and enter the ICD-10 code. Ensure to include the patient's weight and any known allergies.
- Complete the Therapy Order by selecting the Vivitrol dose and specifying any refills or additional orders. Indicate lab order frequency and who will draw required labs.
- Fill out Provider Information, including your name, signature, NPI number, and contact details. If opting out of site selection, list your preferred location.
- For Comprehensive Support, ensure all required documentation is checked off before faxing to Paragon Healthcare at 855.889.2946.
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