Download form - 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the TP ID# for Touchpoints use only. This is essential for tracking your submission.
3. Complete the Referring Prescriber or Facility Information section. Ensure you check all applicable boxes for VIVITROL shipment and provide the prescriber's details, including name, tax ID, DEA number, and contact information.
4. In the Patient Insurance Information section, fill out the patient's name, date of birth, and insurance details. Attach a copy of both sides of the patient’s insurance card as instructed.
5. Provide comprehensive Patient Information including preferred delivery date for VIVITROL and best times to call. Make sure to list any known allergies and concurrent medications.
6. Finally, ensure that all signatures are completed where required, including those from both the prescriber and patient. Review all entries for accuracy before submitting.

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