For Healthcare ProfessionalsVIVITROL ( for 2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. 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.
4. 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.
5. Fill out Provider Information, including your name, signature, NPI number, and contact details. If opting out of site selection, list your preferred location.
6. For Comprehensive Support, ensure all required documentation is checked off before faxing to Paragon Healthcare at 855.889.2946.

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